Youth Spring Retreat 2026

REGISTRATION

Youth Spring Retreat
April 17-19, 2026
Registration Deadline April 1, 2026

$175/student
(50% discount for each additional sibling*)
*All children must be registered at once to receive this discount.

This form must be filled out & submitted by the student's parent or legal guardian.

Number of Students You are Registering*

Student #1

Name - Student #1*

First NameLast Name

Grade - Student #1 *

E-mail - Student #1

Cell Phone - Student #1

Format: (000) 000-0000.

Guest Of

Cost for Student #1

Student #2

Name - Student #2*

First NameLast Name

Grade - Student #2*

E-mail - Student #2

Cell Phone - Student #2

Format: (000) 000-0000.

Guest Of

Cost for Student #2

Student #3

Name - Student #3*

First NameLast Name

Grade - Student #3*

E-mail - Student #3

Cell Phone - Student #3

Format: (000) 000-0000.

Guest Of

Cost for Student #3

Student #4

Name - Student #4*

First NameLast Name

Grade - Student #4*

E-mail - Student #4

Cell Phone - Student #4

Format: (000) 000-0000.

Guest Of

Cost for Student #4

Parent/Guardian Information:

Name - Parent/Guardian*

First NameLast Name

Email - Parent/Guardian*

example@example.com

Phone Number #1 - Parent/Guardian*

Format: (000) 000-0000.

Phone Number #2 - Parent/Guardian

Format: (000) 000-0000.

Medical Information:

Medical Insurance Company*

Policy Number*

Physician's Name*

Physician's Phone Number*

Format: (000) 000-0000.

YesNo

If yes please explain. Please include names of medications/dosages that must be taken.*

YesNo

If yes, please describe allergy and treatment:*

YesNo

If so, please explain their special diet:*

Parental Agreements:

YesNo

Notes & Payment Information:

Any questions/comments for Pastor Josh?

Scholarship Request

Please explain reason needed and amount requested (half or full scholarship)

Total Due$

Pay Online NowBring/Send a CheckScholarship Requested (For partial scholarships, submit balance due via check.)

Online Payment Amt $

USDYouth Spring Retreat

Check Instructions:

Checks should be made payable to Ebenezer BFC, Memo: Youth Spring Retreat
Please hand in or mail to the church within a week after you register (3100 Hecktown Rd. Bethlehem PA 18020).