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

Gender

Name of School

Are you currently part of a youth group in a CCCU church?

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

If you checkmark this box, you are promising to attend all activities and services, to obey all the rules of the retreat center and the grounds, and to conduct yourself as a lady/gentleman at all times.

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

Is Your Child up to date on all immunizations?

Other

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.

Does your child require a gluten-free or lactose-free diet?

Allergies

Is your child able to participate in strenuous activities?

Other

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.

I, as a parent or guardian, agree with the above statement.

I, as a parent or guardian, agree to allow camp staff to take pictures of my child for social media updates & various Evangelical Christian Youth promotions.

Other

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

2026 Spring Retreat Registration

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

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