2025 Message Retreat Registration Form

Health Insurance Information
Do you have health insurance?*

YesNo
Name of Health Provider*
Provider Phone Number*
Please enter a valid phone number.
Member ID*
Group Number*
Do you have any food allergies or prescribed medication that we should be aware of?*

YesNo
If Yes, please specify all food allergies and/or prescribed medication taken.*

Agreement & Signature
Please read through "The Message Retreat Covenant Consent Form 2025" which includes the:

1. Press & Medical Release

2. Code of Conduct

The Message Retreat Covenant Consent Form 2025

All registrants and parent (if applicable) must agree to the covenant consent form to attend this retreat.
Does you registrant and parent (if under the age of 18) acknowledge that I have read and agree to the Message Retreat Press and Medical Release on this form? I have also read and agree to abide by the Message Retreat Code of Conduct & Electronics Agreement.*

YesNo
Registrant Name*

First NameLast Name
Signature*

Clear
Name of Parent/Guardian*

First NameLast Name
Parent/Guardian Signature*

Clear
Should be Empty:

Registrant Information