Clone of 2025 PK/MK Retreat

Church Attending With: **Please note that churches are listed by city first***

City - Church Name (Ex: Minden - First A/G)*

Child's Name*

First NameLast Name

Parent/Guardian Name*

First NameLast Name

Parent's Phone Number*

Please enter a valid phone number.

Age*

Grade*

Gender at Birth*

E-mail*

example@example.com

T-shirt Size*

Favorite Drink*

Favorite Snack*

Is your Student driving to PK Retreat?*

If needed, is your student allowed to transport other Pk's off campus to activities within the Alexandria/Pineville area?*

Please check if camper has any of the following conditions:

Any Medical Facts We Should Know or Medications Camper Will Be Taking:

Date of most recent tetanus shot:

Insurance Company*

Policy #*

I give my permission for my child to participate in all related activities while on the PK - MK Retreat. I give my consent for the first aid personnel or other appointed authority to administer proper medication and/or treatment as needed. In the event I cannot be notified of necessary emergency surgery or other medical treatment for my child, I give my permission for the attending physician to treat my child in the manner he/she recommends.

I also understand participants are liable for damages caused intentionally or maliciously. Damage caused by a participant will be billed directly to the participant responsible and/or their legal guardian.

I also give permission for photos (individual or group) & video footage to be taken of my student at this event, to be used in the best interest of Louisiana Student Life Department, as well as the Louisiana District Council of the Assemblies of God.

Please Check the Box below if you give permission and understand the terms listed above.

I give permission & understand the terms listed above*

YesNo

Parent/Guardian Signature (Required)*

Relationship to student*

2026 PK & MK Retreat Online Registration

Contact Info

Medical Info

Student's Insurance Information

Parental Authorizations