Crosby Church Youth Winter Retreat 2023

Student's name*

First NameLast Name

MaleFemale

Age*

Grade*

School*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student's mobile phone number*

Area CodePhone Number

Mom's mobile phone number*

Area CodePhone Number

Parent email address

example@example.com

Dad's mobile phone number

Area CodePhone Number

Home phone # if applicable

Area CodePhone Number

Emergency contact*

First NameLast Name

Emergency contact phone number*

Area CodePhone Number

Physician's name*

First NameLast Name

Physician's Phone number*

Area CodePhone Number

YesNo

Policy #*

Insurance co.*

List any Food Allergies or Other Allergies we need to know about*

List all prescriptions your student takes*

Dosage and usage of prescription medicine *

Other physical limitations, restrictions or concerns

To take part in the Activate Youth Retreat

Liability:

In consideration of the acceptance of the right to participate, entrants, participants, and spectators by execution of this form, release & discharge Crosby Church, the officers and members of Crosby Church and/or anyone else connected with management or presentation from any & all known and unknown damages, injuries, losses, judgments and/or claims from any causes whatsoever that may be suffered by any entrant to his/her person or property; further each entrant agrees to indemnify all the foregoing entries, firms, persons and bodies from any and all liability occasioned from the conduct of entrants or any participant assisting or cooperating with entrant and under direction or control of entrant.

Media Release:

In consideration of the foregoing event, participant, family and guests agree to permit Crosby Church use of their names, photographs for publicity & advertising (including newspapers, magazines, radio & television) before and after the event, and do hereby relinquish any rights to any such photographs taken in connection with the event, and give permission to publish or dispose of said photographs to Crosby Church.

Medical Care Release:

In addition I give my permission for proper medical care to be given to my son / daughter by the proper medical authorities in any case as is deemed necessary.

Transportation Release:

I hereby give my permission for my child the described participant to travel in appropriately supervised and safe transportation to and from any excursion associated with this event.

Signature of Parent or Guardian of student going

Signature of Adult going to the retreat

My Products

Winter Retreat Deposit$75.00

Winter Retreat FULL$150.00

Winter Retreat Adult$75.00

Total $0.00

Credit Card