Student Registration - 2026 SECCC Youth Winter Retreat

2026 SECCC Youth Winter Retreat - Student Registration

Register as a student for the upcoming youth retreat. Please complete all required fields. Waiver and consent required. Registration Deadline to get a t-shirt: December 13, 2026. If you have any questions, please contact youth@acccn.org
Full Name

First NameLast Name
Preferred Name (if different)
Gender
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Grade
Please select one option.
Church
T-shirt Size
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address
example@example.com
Student Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian and Medical Insurance Information
Parent/Guardian Name

First NameLast Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone
Please enter a valid phone number.Format: (000) 000-0000.
If I cannot be reached in the event of an emergency, the Adult Volunteers in charge is authorized to act on my behalf to hospitalize, secure property anesthesia, or to order any injection(s) for my child. My child also has my permission to be transported to and from this activity by car or van. I understand the driver of the vehicle will be licensed, insured, and will do all driving in accordance to the law.
In order for the Group to expedite treatment for any unforeseen emergency, please provide the student's medical insurance information below.

The Group will keep the information confidential.
Medical Insurance Provider
Medical Insurance Policy Number
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Special Concerns or Needs
Food Allergies and Dietary Restrictions can be made in advance to Shocco. If you have a food allergy or dietary restriction please complete this form before Dec 14, 2026.

Shocco Food Allergies and Dietary Restrictions
Will your youth stay with you at night instead of housing with the youth?
Please specify any special concerns or needs other than food allergies or dietary restrictions.
Waiver and Consent
Please complete the Shocco Waiver & Release Form in the link below. After you click the link below, a new window will open for you to complete the waiver. Then you can return to the registration form tab to continue your registration process. The "Event Name" for the waiver form is "2026 December 31 Atlanta Chinese Christian Church North Youth Retreat". 2026 Shocco Youth Retreat Waiver
Shocco Waiver Form completed
Assumption of Risks and Waiver of Liabilities Relating to COVID-19 and Other Infectious Diseases The Atlanta Chinese Christian Church ("the Church") has put into place preventative measures to reduce the spread of COVID-19 and other infectious diseases; however, the Church cannot guarantee that you or your child or children or other family members will not become infected with viruses. Further, attending the Church or participating in any of its sponsored activities could increase your risks and your family member's risk of viruses. By checking the box below, I acknowledge the contagious nature of COVID-19 and other infectious viruses voluntarily assume the risk that my children or I may be exposed to or infected by viruses by participating in Church congregational worship or other church sponsored or approved activities and that such exposure or infection may result in personal injury, illness, permanent disability and death. I understand that the risk of becoming exposed to or infected by COVID-19 and other viruses through the Church's sponsored activities may result from the actions, omissions, or negligence of myself and others, including but not limited to, Church employees, volunteers, and program participants and their families and guests. I voluntarily agree to assume all the forgoing risks and accept sole responsibility for any injury to my children or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my children may experience or incur in connection with my or my children's attendance at the Church or participation in the Church's programing ("Claims"). On my behalf and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the Church, its employees, agents, and representatives and governing bodies and members of such bodies from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Church, its employees, agents, and representatives, whether a COVID-19 or other virus infection occurs before, during, or after participation in any Church program.
Signature

I, the parent or legal guardian of the attending youth under the age of 18, am agreeing to the Assumption of Risks and Waiver of Liabilities stated above.
Payment and Cancellation Policy
Select a payment below then click on the "Register and Pay" button. Cancellations accepted until 12/10/2026 minus any non-refundable merchant fees(up to $5 per person). Cancellations after 12/10/2026, a $40 fee will be applied. No cancellations will be accepted after 12/14/2026 and no refunds will be issued. Cancellation requests must be made in writing and submit to youth@acccn.org.
Will your youth check out early from camp? (No discount for arriving late or leaving early)
Planned check-out date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
prevnext( X )
Student Registration
$275.00

Total

$0.00

Payment Methods

Debit or Credit Card

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

Should be Empty:

2026 SECCC Youth Winter Retreat - Student Registration

Parent/Guardian and Medical Insurance Information

In order for the Group to expedite treatment for any unforeseen emergency, please provide the student's medical insurance information below.

Special Concerns or Needs

Waiver and Consent

Payment and Cancellation Policy

*

Payment Methods