2025 YOUTH Spring Retreat PSL Registration

Youth Participant Registration

Youth Retreat February 21 7 pm - February 23 9:30 am
Church*
If Other, what church will you be attending with
Youth Name*

First NameLast Name
Grade*
Age of child
Youth Council

YesNo
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/guardian Name (Emergency Contact 1)*

First NameLast Name
Parent/guardian Cell Phone Number (Emergency contact 1)*

Area CodePhone Number
Parent/guardian email*
example@example.com
Church Youth Advisor/Chaperone*
Name
Advisor/Chaperone Email*
example@example.com
To be filled out by Parent/Guardian of Participant
List any DIETARY allergies/ restrictions*
If none, please enter none
I require a epipen*

YesNo
List any non-Dietary allergies (bee stings, etc)*
If none, please enter none
I require an inhaler*

YesNo
List any medical or other conditions leadership team should be aware of. *
If none, please enter none
Medical Authorization and Release*

Should my child sustain or incur any accident or illness while at the event, I hereby authorize the Director,the Health Care provider or chaperone to execute any and all documents in my behalf, including necessary releases, which might be required by a medical facility to perform emergency care.I do not give permission
Photo release and permission to contact*

I give permission for any photos or videos taken of my child during the event to be used by the Presbytery of Sheppards and Lapsley and/or Living River for use of the public relations of the program.I do not give permission
Accident Insurance Disclaimer*

I understand I am responsible for all incurred medical expenses while my child is a participant at Living River
Community Guidelines*

I understand I will receive an email with information about what items to bring or not to bring to the retreat as well as community expectations for the weekend. I understand my child is responsible for knowing and adhering to these and may be sent home if not in compliance.
Parent Signature*

Clear

Payment
Type payment -- Cost $80*

Bill the churchPay by check - Payable to Presbytery of Sheppards & LapsleyPay by credit cardBill Presbytery

**Credit card Payment

****** IMPORTANT -- Please click "add to cart" box below

Add to cart - Please click->->->

Spring 2025 retreat Click box to left$80.00

Total $0.00

Credit Card

Please submit your registration! See you at Living River.
Should be Empty:

Youth Participant Registration

To be filled out by Parent/Guardian of Participant

Payment

**Credit card Payment

Credit Card

Please submit your registration! See you at Living River.