HS Reset Retreat Registration
January 17 - 19, 2025 | Mt. Lebanon Retreat Center
Participant Name
*
First Name
Last Name
Participant Phone Number
*
Please enter a valid phone number.
What grade is the participant in?
*
9th Grade
10th Grade
11th Grade
12th Grade
Participant Gender
*
Male
Female
Please select a t-shirt size for the participant:
*
Please Select
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult 2XL
Adult 3XL
Parent Name (Emergency Contact):
*
First Name
Last Name
Parent Email:
*
example@example.com
Parent (Emergency Contact) Phone Number:
*
Please enter a valid phone number.
Please list any food allergies for the participant below:
If there are none, you may skip this questions
Please list any allergies to medicine for the participant below:
If there are none, you may skip this questions
Please list any medical concerns for the participant below:
If there are none, you may skip this questions
Please list all prescription medications for the participant below:
If there are none, you may skip this questions
Please list social or emotional concerns for the participant below:
If there are none, you may skip this questions
Registration Cost:
*
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HS Reset Retreat Deposit Only
The remaining $150 is due by January 17, 2025.
$
50.00
HS Reset Retreat Full Payment
$
200.00
I Would Like to Talk to Kim About Scholarships
$
Free
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
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