Youth Retreat Registration

Medical & Emergency Information
Participant Name as it appears on their health card

First NameLast Name
Participant Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name
Name
Phone Number

Area CodePhone Number
Back-up emergency contact (optional)
Name
Phone Number of back-up (if you named someone above)

Area CodePhone Number
Health numbers

6 digit9 digit (Manitoba only)
If not covered by Manitoba or Ontario Health, list your health insurance provider

Insurance ProviderPolicy Number
Is the participant prescribed an inhaler or epi-pen? If yes, please explain any instructions. If not, type "no".
Please be sure it is clearly labelled with their name.
Names and dosage of other medications that the participant will bring with them that need to be taken over the weekend:
Please only send the amount the participant needs for the weekend, and clearly label it with their name.
Will the above medications be:

Self AdministeredAdministered by an adultN/A
If necessary, this participant may be given:

TylenolAdvilOther
Additional medical info, such as allergies, that a health care provider would need to know, if giving emergency treatment.

Informed Consent and Agreement of Participation

While every precaution will be taken for the safety and good health of participants, some sports and activities carry with them the inherent risk of personal injury. I understand that by allowing this registrant to participate in the activities of this supervised event, I am exposing them to inherent risks and hazards. I accept all these risks and hazards and agree that by allowing them to participate in these activities, I acknowledge that I will be responsible for any injury or other loss which may occur during their participation in these activities.

I, authorize the leaders, or their designate, to permit emergency treatment for this registrant if it is deemed necessary. (Efforts will be made to contact parent/guardian before treatment is given.)

I, parent/guardian, agree to hold blameless the Prairie to Pine Region of the United Church of Canada, its personnel, leaders and council from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of this event, as well as of any medical treatment authorized by the supervising individuals providing leadership at the retreat.

By clicking submit at the end of this form, I am acknowledging that I, the parent/legal guardian of the above named participant:
- am agreeing to allow the participant to attend this event, and
- have read and agree to the above statements, and
- state that any information given in the registration above is correct.
If space allows, and given parent/guardian permission, youth may be allowed to change their choice of sleeping space after arrival at the event.*

I, parent/guardian of the registrant am willing for this registrant to make that choice.I, parent/guardian of the registrant would like a phone call to talk it over with them, if this registrant wishes to move to a different sleeping space.

Zeebu 2026 Youth Retreat

Accessibility

Medical & Emergency Information

Registration Fees