Youth Service Weekend at Rock Point Registration
Registration Type
*
Please Select
Youth Participant - Friday to Sunday
Youth Participant - Saturday Only
Elementary Participants - Saturday Only
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Contact Information
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Participant Registration
Name of Registrant
*
First Name
Last Name
Registrant Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Registrant Date of Birth
*
-
Month
-
Day
Year
Date
Grade
Please Select
6th
7th
8th
9th
10th
11th
12th
Other
If 'Other,' please explain
Congregation
*
Please Select
Arlington- St. James'
Barre- Church of the Good Shepherd
Bellows Falls- Immanuel Church
Bennington- St. Peter's
Bethel- Christ Church
Brandon- St. Thomas & Grace
Brattleboro- St. Michael's
Burlington- Cathedral Church of St. Paul
Chester- St. Luke's
Colchester- St. Andrew's
Enosburg Falls- St. Matthew's
Essex Junction- St. James
Fairlee- St. Martin's
Fair Haven- St. Luke's
Hardwick- St. John the Baptist
Island Pond- Christ Church
Killington- Church of Our Saviour
Lyndonville- St. Peter's
Manchester Center- Zion
Middlebury- St. Stephen's
Montpelier- Christ Church
Newport- St. Mark's
Northfield- St. Mary's
Norwich- St. Barnabas E
Proctorsville - Gethsemane
Randolph- St. John's
Rutland- Trinity
Shelburne- Trinity
Sheldon- Grace Church
South Burlington- All Saints
Springfield- St. Mark's
St. Albans- St. Luke's
St. Johnsbury- St. Andrew's
Stowe- St. John's in the Mountains
Swanton- Holy Trinity
Underhill- Calvary
Vergennes- St. Paul's
Waitsfield- St. Dunstan's
Wells- St. Paul's
White River Junction- St. Paul's
Wilmington- St. Mary's in the Mountains
Windsor- St. Paul's
Woodstock- St. James
Gender
Is there anything you would like the adult staff to know about your gender, gender identity, or pronouns?
Medical Information
Food Allergies or Restrictions
*
Important medical information (not related to food) and special needs
List all medications registrant has permission to bring. Medications must come in original packaging with clear dosing instructions. Staff will contact parent/guardian to set up a medical disbursement plan while youth is participating in event.
Health Insurance Company & Policy Number
*
Primary Care Physician's Name
*
Physician's Phone
*
Parent/Guardian Consent
Photos of my child may be used for publicity purposes, including on social media.
*
Yes
No
Videos of my child may be used for publicity purposes, including on social media.
*
Yes
No
I give permission for my child to participate in Youth Events. I absolve the Diocese(s), the sites and churches, and their employees and volunteers from responsibility for accident or injury which may occur during any aspect of this event, including transportation to, from and during the event. I give permission to the adults to give medications and to provide or get emergency medical treatment, and I will be financially responsible for such treatment. (Parent/Guardian - typing your name below indicates your agreement. This is required for your child to attend)
*
Payment
This event is being presented at a sliding scale for participants of $50, $75, or $100. How would you like to pay:
*
Online Now - Visit https://tinyurl.com/yz4x6nfr to pay.
Later - I will send a check to the Episcopal Diocese of Vermont with "Youth Retreat Fee" in the memo line at 5 Rock Point Road.
My church will pay the fee - My church will be sending one check for all youth participants from our congregation.
Submit
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