4th Day Retreat 2019
January 4th, 5th, 6th
PLEASE READ ENTIRE LETTER!
Kiddie Keepwell Center
35 Roosevelt Drive, Edison NJ 08837
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Age
Email
example@example.com
Name Of Current Church
Phone Number
-
Area Code
Phone Number
Do you have any musical abilities? If so, please list below and let us know if you're willing to share.
Guitar? Piano/Keyboard? Vocals? Etc.
Do you have any MEDICAL ISSUES, or on and MEDICATION or on a SPECIAL DIET?
Yes
No
If Yes, Please List
If Yes, Please list doctor's name and phone number.
Doctor
Phone Number
Shirt Size
Small
Medium
Large
X-Large
XX-Large
Parents
Please fill out this section if you are under 18 years of age. Otherwise, please skip to emergency contact.
Mother
First Name
Last Name
Father
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
-
Area Code
Phone Number
In case of an Emergency, please provide a phone number and the name of a parent or guardian who can be reached during the weekend.
Name
Number
Relationship to Applicant
Does Search have permission to display Retreat Photos of your child on our web site?
Yes
No
Please Read Carefully Before Signing
Be Sure to read the accompanying letter that describes briefly what the weekend is about. THIS IS A NON-SMOKING AND DRUG FREE WEEKEND. Any drugs found will be confiscated and the applicant may be sent home. This weekend has been planned in order to assist in the Christian growth of teenagers and adults. It is designed to be informative, spirit filled and fun once the rules stipulated above are followed. By signing below you indicate that you have read and understood the above rules and the letter describing briefly what the weekend is about.
Applicant
Parent Or Guardian
Retreat Cost $140 Per applicant. You will be forwarded to Paypal.
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USD
$140
Payment:
You may submit the application with or with out payment, If you choose to submit with out payment, please send a check for $140 made payable to 'Boonton UMC' with 'Search' in the memo. You may also choose to print the application and send payment in to the address listed below Please Send Printed Application and Check to: Rev. Dianna Stone 73 Old Highway 28, Whitehouse Station, NJ 08889
For more information please contact:
Please Send Printed Application and Check to: Rev. Dianna Stone (Spiri†ual Leader) (973) 590 - 6642 Michelle Albano (Retreat Coordinator) (973) 634 - 5904
Submit
Print Form
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