Youth Retreat Permission Slip & Waiver

East Region Youth Retreat 2026

February 14-16, 2025 - Camp Ladore, Waymart, PA
Parent/Gaurdian Name*

First NameLast Name
Parent/Guardian Phone Number*
Please enter a valid phone number.
Parent/Guardian Phone Number 2
Please enter a valid phone number.
Parent/Guardian Email*
example@example.com
Parent/Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Emergency Contact:*

First NameLast Name
Additional Emergency Contact Number:*
Please enter a valid phone number.
Student's Name*

First NameLast Name
Sex:*
Date of Birth:*

MonthDayYear
Date
Please list any medications (or type 'none'): Medications*
Please list any food allergies (or type 'none'): Allergies*
Health Insurance Info.
Company Name: Insurance company*
Policy #: Policy #*
Ask a question
I am interested in chaparoning, please contact me.

Yes
By submitting this form I hereby give my child permission to attend this event sponsored by the The Experience Vineyard Church. I understand that RVC personnel and volunteer chaperones will supervise this activity. I release the Experience Vineyard Church staff, volunteer chaperones and all funding sources from any liability or other legal action.

I hereby authorize any director, adult leaders, or agent of the Youth or Children's Ministry of The Experience Vineyard Church to obtain emergency medical treatment for my child at any time during the above named activity. I understand that an attempt will be made to notify the parents first. If the parents are not available, however, the youth will be taken to the emergency room at the nearest hospital as circumstances may warrant.

Parents agree to review the 'Teen Code of Conduct' below with their child.

It is imperative that each child be picked up at the conclusion of the activity. It is your responsibility to ensure that your child is picked up promptly.
TEEN CODE OF CONDUCT

I understand that attending this event is a privilege and
not a right to attend.

·       I understand that attending this event is a privilege and not a right to attend.

·       I will conduct myself with an attitude of excellence and appropriate behavior from the moment we leave RVC until we return to RVC.

·       I will honor and respect my leaders and chaperones who are overseeing this trip

·       I will do my best to include other members of my youth group.

·       I will attend all meetings and small group talks while at the retreat, if applicable.

·       If I am dating someone in the youth group I am not to be alone with them at any time during this event.

·       I will not go off with someone of the opposite sex from my group or from any other youth group attending this event.

·       I will adhere to the rules set for the campground when we get there and also respect the facility property.

·       My speech and words will be positive, especially concerning each member who is in our group, as well as someone else’s group.

·       I will not go off with any other leader from another youth group of the opposite sex without having a friend with me.
- · If I see an injustice being done to anther teen on this retreat, I will tell my leaders. (ex; bullying, making fun of, )
  
  · If another adult leader is making me feel uncomfortable, I will tell my group leader or chaparone right away!
  
  DO NOT BRING!!!!!!!
- Electronics (iPod, PSP, handheld games, etc)
- Weapons of any kind (hand knives, lighters etc .)
- Drugs, Tabacco, or Alcohol (No aspirin, if your
  parents want you to have some you need to give it
  to a leader.)
Teen Code of Conduct - Teen Signature*

Clear
Each parent is required to submit this signed permission slip prior to the date of the activity. If NO PERMISSION SLIP IS RECEIVED, THE YOUTH/CHILD WILL NOT BE PERMITTED TO PARTICIPATE.
Parent/Guardian Signature*

Clear
Should be Empty:

East Region Youth Retreat 2026