FCS Overnight Retreat Form, 2025

Fellowship Christian School High School "Overnight" Retreat Form

Please complete all sections to allow your child to attend the High School "Overnight" Retreat from Monday, March 31-Wednesday, April 2.
Camper/Participant Information

OVERNIGHT RETREAT FORM DUE BY MONDAY, MARCH 17, 2025
Participant/Camper Name #1*

First NameLast Name
Birth Date*

MonthDayYear
Gender*

MaleFemale
Participant/Camper Name #2

First NameLast Name
Birth Date

MonthDayYear
Gender

MaleFemale
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent E-mail*
Parent E-mail
example@example.com
Parent E-mail
example@example.com
Parent Name*

First NameLast Name
Phone Number 1*

Area CodePhone Number
Parent Name

First NameLast Name
Phone Number 2

Area CodePhone Number
Emergency Information

This contact must be able to be reached at all times.
Emergency Contact #1 Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Emergency Contact #2 Name (Non parent)*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Camp/Retreat Info & Requirements
Dates & Location: The FCS Overnight Retreat will be held from Monday, March 31-Wednesday, April 2. It is being held at the Millersylvania Retreat Center.
- Location Address: 12245 Tilley Rd SW, Olympia, WA 98512
- Location Website: https://parks.wa.gov/find-activities/retreat-centers/millersylvania-retreat-center
Housing: Students will stay in the assigned cabins. Males and Females will be in separate buildings with male chaperones with the males during sleeping hours/lights out and female chaperones with the females during sleeping hours/lights out. Male and female students/campers/participants are never allowed to enter those of the opposite sex's camp housing quarters or bathrooms.

Students/Campers/Participants are never allowed to leave the Retreat Center grounds without an adult chaperone and must be within sight and hearing distance of an adult chaperone at all times. Most (if not all) activities will be done as a whole group.

Departure: 9:30am on Monday, March 31, from FCS
- Students are required to have all of their items packed and ready at morning drop off, at school (by 8:30am).
  - All luggage must be labeled with a student's name (you can use luggage tags).
  - All packed items and luggage will be checked by a staff member before departure.
  - All items need to be items listed as okay to take with the student on the packing list handed out.
  - Extra items should not be packed, to allow for room in the vehicles.
Return: About 4pm on Wednesday, April 2, at FCS
- Parents will be texted upon return so they are able to come and pick up their children from FCS.
- As a reminder, school will still be in session for students in Pre-K through Grade 8.
Participant Medical & Insurance Information
Primary Care Physician Name
Name of Practice
Physician Phone Number

Area CodePhone Number
Date of last Tetanus shot (Participant 1)

MonthDayYear
Date
Date of last Tetanus shot (Participant 2)

MonthDayYear
Date
Medical Insurance Company
Medical Insurance Phone Number

Area CodePhone Number
Insurance Policy/Group ID#
Policy Holder's Name

First NameLast Name
Drug Allergies or Other Allergic Reactions:
Drug/medicine, food, and/or environmental.
Dietary Needs/Restrictions (Due to allergy):
Activity Restrictions:
Medication(s), Dose & Dispensing Instructions:
List all medications the participant will take during the trip/retreat/event. This includes any prescription, non-prescription, herbal supplements and vitamins. All medications must be given to the retreat/event leader and must be in the original container, complete with dispensing instructions. Participants are not permitted to carry any medication on them and will be sent home at the parent/guardian's expense if they do.
Health and/or Additional Medical Information/ Conditions:
Example: asthma, diabetes, epilepsy, etc. & any other pertinent information.
Please Select one of the following

Contact me or get medical help if my child has any minor medical concerns.I give permission for an adult leader to give my child approved over-the-counter medications as directed, on an as needed basis to treat non-emergency medical conditions.
Parental Consent; Student & Parent Agreement
Parental Consent, Release & Agreement

The undersigned does hereby give consent for my child(ren), named above, to attend and participate in any Fellowship Christian School youth ministry activities, events, retreats & retreat activities during the period of March 31, 2025-April 2, 2025.

LIABILITY RELEASE: In consideration of Fellowship Christian School allowing the Participant(s) to participate in youth ministry (worship, meeting, activities, events, retreats, lock-ins, trips), I, the undersigned, do hereby release, forever discharge and agree to hold harmless Fellowship Christian School, its pastors, directors, employees, volunteers and teachers (collectively herein "FCS") from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned and the Participant(s) while involved in the youth activities and care. I, the parent or legal guardian of this Participant(s), hereby grant my permission for the Participant(s) to participate fully in all activities and care, including trips away from the school premises. Furthermore, I, on behalf of my minor Participant(s), hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation, work and activities involved therein. The undersigned further hereby agres to hold harmless and indemnify said FCS for any liability sustained by said FCS as the result of negligent, willfull or intentional acts said Participant(s), including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licenced hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth or Participant pursuant to this authorization.

EARLY RETURN HOME POLICY: Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility and immediately come to pick up the Participant. In addition, trip fees will not be returned.

TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child/youth/Participant to ride in any vehicle driven by an approvd and licensed adult chaperone while attending and participating in activities sponsored by Fellowship Christian School. My child/youth/Participant and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation. Failure to follow this requirement will result in the student needing to be picked up immediately by the parent/legal guardian.

STUDENT REQUIREMENTS & RESPONSIBILITIES: The undersigned agrees to follow all FCS policies and requirements for the High School Overnight Retreat, including everything listed on the linked High School Overnight Flyer & Info Sheet.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Parent Name*

First NameLast Name
Parent Signature*

Clear
Participant Name*

First NameLast Name
Student/Participant Signature*

Clear
Participant Name

First NameLast Name
Student/Participant Signature

Clear
Payment: All high school families will be invoiced via Quickbooks by March 11, 2025. Payment is due no later than Tuesday, March 25, 2025.
Should be Empty:

Fellowship Christian School High School "Overnight" Retreat Form

Camper/Participant Information

Emergency Information

Camp/Retreat Info & Requirements

Participant Medical & Insurance Information

Parental Consent; Student & Parent Agreement

Payment: All high school families will be invoiced via Quickbooks by March 11, 2025. Payment is due no later than Tuesday, March 25, 2025.