Middle School Retreat Registration Form

Upon submission, you will be redirected to fill out a waiver from the Camp and Retreat Center.

The digital waiver is a requirement for all guests. If your group needs to help some people sign this (i.e those who are not tech savvy or do not have phones/ computers) you may do so in your meeting room prior to coming to the desk to check in.

Please know we cannot check your group in until all waivers from your guests have been signed.
Are you registering as a:
Participant's Name

First NameLast Name
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Grade
Gender
Number
Email
example@example.com
Parental Consent Form
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Phone Contact Number(s):
Please enter a valid phone number.Format: (000) 000-0000.
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact (other than parent/guardian):
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Health/Medial Insurance Co:
Policy Number:
List Allergies or Medical Conditions:
Any Prescription Medications being taken at this time:
As a parent/legal guardian of type child's name*, I have reviewed the information about the event, and give permission for the subject of this release to be involved I the overall activities.

I/We have reviewed the rules of the activities and agree that the subject of this release will abide by them. I/We also acknowledge that if the subject of the release must return home early for discipline violations, it will be at my/our expense.

I/We understand all reasonable safety precautions will be always taken by Southern Calvert Baptist Church and its agents during the events and activities. I/We authorize any treatment by an accredited hospital and/or physician deemed necessary for the subject of the release in case of an emergency.

I/We understand the possibility of unforeseen hazards and know the inherent possibility of risk. I/We agree not to hold Southern Calvert Baptist Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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Student Registration

Leader/Parent Registration
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Student Registration

Student: Youth Impact - Middle School Retreat Registration
Cost per student + service fee

$51.52



Leader/Parent Registration

Parent: Youth Impact - Middle School Retreat Registration
Cost per leader/parent + service fee

$26.01



Leader: Youth Impact - Middle School Retreat Registration
Free



Total

$0.00
Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info
Should be Empty:

Parental Consent Form

Emergency Contact (other than parent/guardian):

My Products*

Payment Methods

My Products