Clone of 2025 FALL RETREAT REGISTRATION

Camper Information

Camper's Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Camper Cell #

Format: (000) 000-0000.

Camper E-Mail

example@example.com

Birth Date*

MonthDayYear

Grade at time of camp*

Age at time of retreat*

Adult T-Shirt Size*

MaleFemale

Name of School

YesNo

Church Name*

Youth Leader's Name

Youth Leader's Phone Number

Format: (000) 000-0000.

If your student was invited by a friend to this retreat, place their name here!

Parent/Guardian Information

Parent/Guardian #1*

First NameLast Name

Phone Number*

Format: (000) 000-0000.

Alt Phone Number

Format: (000) 000-0000.

Parent E-mail*

example@example.com

Parent/Guardian #2

First NameLast Name

Phone Number

Format: (000) 000-0000.

Alt Phone Number

Format: (000) 000-0000.

CAMPER AGREEMENT

I Agree

Today's Date

Date

MEDICAL INFORMATION
The information below is necessary for the retreat nurse and/or coordinators to adequately treat your child in the event of an injury or illness. All information will remain confidential.

Physician Name*

First NameLast Name

Physician Phone Number*

Format: (000) 000-0000.

Insurance Company*

Write N/A if not available

Policy/ID Number*

Write N/A if not available

YesNoOther

Medications your child is currently taking*

Please add in scheduled times and dosage amount. All medications must be turned in to the camp nurse at check-in. Medications must be in their original container with the camper's name and the name of the medication on the bottle.

Yes. Just Gluten-FreeYes. Both Gluten and Lactose-FreeNo

Allergies*

YesNoOther

Chronic or existing illnesses (mental health included) and other needed health information.*

Emergency Contact #1 Name*

First NameLast Name

Relationship*

Phone Number*

Format: (000) 000-0000.

Emergency Contact #2 Name*

First NameLast Name

Relationship*

Phone Number*

Format: (000) 000-0000.

PARENT OR GUARDIAN RELEASE

I understand that my child is under the supervision of quality leadership while attending camp. However, I also understand that my child will be participating in activities that could cause possible injuries, such as swimming, sports, boating, tubing and construction projects. I understand that great care is taken to ensure the safety of my child but that some of the activities may be dangerous by nature. Therefore; I release the camp and its governing board(s) as liable or responsible for injuries in the event of a lawsuit. I also give permission for my child to be transported off campgrounds for participation in camp activities. Furthermore, I authorize the Camp Coordinator, Assistant Coordinator, Camp Nurse, or any other official they deem appropriate to seek any necessary examination, treatment and/or hospital care for the camper named above under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine in the State of Ohio. I grant permission for photographs to be taken of my child for camp directories and for publicity use.

Yes

YesNoOther

RETREAT PAYMENT INFORMATION

Please share in detail the person or church that will be paying for this student's fee.*

Write N/A if payment will be made through a scholarship fund or no payment is being made due to a waived fee.

If paying for multiple retreat fees, please place each student's name here.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE. I ACKNOWLEDGE THAT ALL OF THE ABOVE INFORMATION IS TRUE.

Signature*

----------------*

First NameLast Name

PLEASE MAKE PAYMENT ONLINE OR SEND CHECKS PAYABLE TO "CCCU" WITH YOUR STUDENT'S NAME AND "SPRING RETREAT" WRITTEN ON THE MEMO LINE.

Send checks to:
CCCU ECY
1553 Lancaster Pk
Circleville, OH

Payment Options **please click on box to confirm your option*

Sending a Check

*ECY and CCCU staff will verify that a check was received

$ Free Quantity

Spring Retreat Full Payment

$100.00 Quantity

Spring Retreat Half Payment

*For those who have been awarded a half scholarship or your church is covering half of the cost

$50.00 Quantity

Total

$0.00

2026 Spring Retreat Registration