Justified Fall Retreat Registration & Parent Permission

Justified Fall Retreat Registration & Parent Permission

Complete this multi-page registration as the parent/legal guardian, and do not enter any medical information—paper medical forms are required before attendance.
Student and Parent/Guardian Information
Student Full Legal Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Grade
Age
T-Shirt Size
$30 Registration / T-Shirt Fee
Select the statement that applies.
$30 Registration / T-Shirt Fee Status
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
ZIP Code
Student Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Student Email
example@example.com
Parent/Legal Guardian 1 Full Name

First NameMiddle NameLast Name
Relationship to Student
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Parent/Legal Guardian 2 Name

First NameMiddle NameLast Name
Relationship to Student
Emergency Contacts
Emergency Contact Name

First NameMiddle NameLast Name
Relationship to Student
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Emergency Contact Name

First NameMiddle NameLast Name
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Paper Medical Form Acknowledgment
Acknowledge the online form does not collect medical information
Acknowledge the separate paper medical, medication, and emergency authorization form will be completed and returned before the student attends
Acknowledge medical information will not be entered in any open-response field on this online form
Code of Conduct Review
Please review the Pine First Baptist Youth Code of Conduct before signing. Review the Pine First Baptist Youth Code of Conduct PDF: https://www.pinefbcyouth.com/resources/Pine-First-Baptist-Youth-Code-of-Conduct.pdf. The student and parent or legal guardian must each review it before signing.
Participating student: I have read or had explained to me the Pine First Baptist Youth Code of Conduct, understand it, and agree to follow it.
Parent/legal guardian: I have read the Pine First Baptist Youth Code of Conduct, reviewed it with the student, and agree to support its expectations.
Conduct, Supervision, and Early Dismissal
Conduct, Supervision, and Early Dismissal
I have reviewed the conduct, supervision, and early dismissal expectations with my student.
Student initials
Parent/Guardian Certification and Electronic Signature
Certification Statement
Electronic Submission Consent
Parent Email for Verification
example@example.com
Parent/Legal Guardian Signature
Printed Legal Name

First NameMiddle NameLast Name
Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Water-Activity Decision
Water-Activity Permission Notice
Current Water Ability
Prior Experience With Boats, Kayaks, Canoes, or Paddleboards

Other
Important: Do Not Provide Health Information Online
Water-Related Risk Acknowledgment
Water Decision
Parent Initials Confirming Water Decision
Student Safety Agreement
Parent / Legal Guardian Printed Name for Water Decision

First NameMiddle NameLast Name
Parent / Legal Guardian Signature for Water Decision
Should be Empty:

Justified Fall Retreat Registration & Parent Permission

Student and Parent/Guardian Information

$30 Registration / T-Shirt Fee

Emergency Contacts

Paper Medical Form Acknowledgment

Code of Conduct Review

Conduct, Supervision, and Early Dismissal

Parent/Guardian Certification and Electronic Signature

Water-Activity Decision