Student Retreat Medical Release, Liability & Permission Form

Student's Name*

First NameMiddle NameLast Name

PARENTAL/GUARDIAN CONSENT

I, the undersigned parent/guardian, hereby give permission for the above-referenced student (the "Participant") to attend and participate in the Student Winter Retreat during the period of January 23, 2026 through January 25, 2026. The Student Winter Retreat will take place at Spruce Lake Retreat Center, located at 5389 PA-447, Canadensis, PA 18325.

LIABILITY RELEASE

In consideration of Shelter Rock Church allowing the Participant to participate in the Student Winter Retreat, I, the undersigned parent/guardian, on behalf of myself, my heirs, my executor and administrators, do hereby waive and release, forever discharge and agree to hold harmless Shelter Rock Church, its pastors, directors, employees, volunteers, and agents (collectively "Shelter Rock") from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever, which may be incurred by the undersigned and the Participant while at the Student Winter Retreat.

Furthermore, I, the undersigned parent/guardian, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, damage and expense as a result of participation in the Student Winter Retreat.

I, the undersigned parent/guardian, further hereby agree to hold harmless and indemnify Shelter Rock for any liability sustained by Shelter Rock as a result of the negligent, willful or intentional acts of the Participant, including expenses inccurred attendant thereto.

I, the undersigned parent/guardian, warrant that I have the right to authorize the foregoing.

MEDICAL TREATMENT AUTHORIZATION

I, the undersigned parent/guardian, understand that every effort will be made to contact me in the event of a medical emergency concerning the Participant. However, if I cannot be reached, I hereby give Shelter Rock permission to act on my behalf in seeking medical treatment by qualified personnel for the Participant in the event that such treatment is deemed necessary or advisable for his/her health, safety and welfare.

I, the undersigned parent/guardian, give Shelter Rock permission to take the Participant to the nearest available medical facility and for the Participant to undergo any necessary emergency treatment. I release Shelter Rock and all medical providers from liability in acting on my behalf when rendering such medical treatment.

I, the undersigned parent/guardian, understand that I will be liable and agree to pay all costs and expenses incurred in connection with such medical services rendered pursuant to this authorization.

TRANSPORTATION PERMISSION

I, the undersigned parent/guardian, hereby give permission for the Participant to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in the Student Winter Retreat. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

EARLY RETURN HOME

Should it be necessary for the Participant to return home due to medical reasons, disciplinary action or otherwise, the undersigned parent/guardian shall assume all transportation costs and responsibility.

PRIMARY CARE PHYSICIAN

Name*

Phone Number*

Address*

INSURANCE INFORMATION

Medical Insurance Company*

Phone Number*

Policy/Group ID #*

Policy Holder's Name *

REQUIRED: Please attach a copy of the medical insurance card here.

Browse Files

MEDICATION

List all medications the Participant will take during the Student Winter Retreat. This includes any prescription, non-prescription medications, herbal supplements and vitamins. Medications must be sent with the Participant in their original containers.

(1) Medication Name, which is used for Medication Purpose, in the dosage amount of Dosage Amount.

(2) Medication Name, which is used for Medication Purpose, in the dosage amount of Dosage Amount.

(3) Medication Name, which is used for Medication Purpose, in the dosage amount of Dosage Amount.

MEDICAL CONDITIONS

Students who use inhalers, EPI Pens, etc. must show them to the Student Winter Retreat nurse at drop off. The student will not be allowed to attend without them.

List any medical conditions the Participant has (asthma, diabetes, epilepsy, etc.).

List any allergies (drug/medicine, food, and/or environmental) and the severity and type of reaction.

Please explain any other pertinent information about the Participant (i.e., physical behavioral or emotional) that would be important for the adult leaders to know.

Please notify us if the Participant has any medically necessary diet restrictions.

Emergency Contact 1 Name*

First NameLast Name

Emergency Contact 1 Phone Number*

Area CodePhone Number

Emergency Contact 1 Relationship to Participant*

Emergency Contact 2 Name

First NameLast Name

Emergency Contact 2 Phone Number

Area CodePhone Number

Emergency Contact 2 Relationship to Participant

DEADLINES

1. The early bird discounted price of $220 expires on Dec 15, 2025. The regular discounted price of $250 expires on January 15, 2026. Late pricing of $295 applies after Jan 15, 2026.

2. Please note that registration is non-refundable after January 9, 2026.

3. The final Balance is due by January 22, 2026.

4. (a) This Permission Slip, (b) the Student Code of Conduct Form, and (c) the Spruce Lake form are due by January 22, 2026.

DROP-OFF | PICK-UP

Drop-Off: Students must arrive no later than 2:30 p.m. on Friday, January 23, 2026 at Shelter Rock Church's Syosset Campus, located at 178 Cold Spring Rd, Syosset, NY 11791.

Arrival: We will arrive at Shelter Rock Church's Syosset Campus at approximately 3:00 p.m. on Sunday, January 25, 2026. Leaders will email or text parents/guardians when we are nearing the city with our estimated time of arrival.

PACKING LIST

What to Bring:

Snack for Friday Night on the Bus
Plastic garbage bags for wet clothes (in case of snow or rain)
Warm and modest clothes for two days
Clothes for outdoor activities as the weather permits (gloves, hats, etc.)
Active sportswear and sneakers
Towel
Water Bottle
Toiletries
Sleeping Bag or Blanket (cabins have twin sized bunk beds with fitted sheet only)
Pillow
*Note- no bedding is provided. Students are responsible for all of their own bedding except the fitted sheet.
Bible and Pen (highlighter optional)
Journal
Extra money if interested in snack bar or gift shop items

IMPORTANT: PLEASE RESTRICT YOUR LUGGAGE TO ONE MEDIUM SIZED PIECE!

What Not to Bring:

Cell phones, smart watches, iPads, laptops, gaming devices or other electronics
Headphones/earbuds/Airpods
Skateboards
Drugs, alcohol, tobacco, vape pens (or similar), or illegal substances (If brought, students WILL be sent home at parents’ expense)
Weapons (If brought, students WILL be sent home at parents’ expense)
Non-prescription medicine

I acknowledge that I have fully read this electronic document and agree to the contents contained in it including, but not limited to, the Liability Release and Medical Treatment Authorization.

Student's Name*

First NameMiddle NameLast Name

Parent/Guardian Name*

First NameMiddle NameLast Name

Parent/Guardian Phone Number*

Area CodePhone Number

Parent/Guardian Email*

example@example.com

Parent/Guardian Signature*

Date signed*

Date

PERMISSION SLIP

MEDICAL INFORMATION

EMERGENCY CONTACTS

IMPORTANT INFORMATION

ACKNOWLEGEMENT AND AGREEMENT

SIGNATURE