Infuse/Ignite Registration

Infuse/Ignite Registration
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Gender*

MaleFemale
Birthday*

MonthDayYear
Grade*
Ignite is our Winter Retreat for students ages 12-14 and in 6th-8th grade.
Infuse is our Winter Retreat for students ages 14-18 and in 9th-12th grade.
Payment Information*
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Deposit$25.00

Event

Full Fee$50.00

Total $0.00
A buddy group consists of yourself and one or two other people. Buddies must be requested at time of registration. Buddies must request each other for the request to be considered. Buddies are not required.
Buddy Request #1
Buddy Request #2

Parent/Guardian Information
Main Contact E-mail*
Mother's Name

First NameLast Name
Mother's Home

Area CodePhone Number
Mother's Cell

Area CodePhone Number
Mother's Work

Area CodePhone Number
Father's Name

First NameLast Name
Father's Home

Area CodePhone Number
Father's Cell

Area CodePhone Number
Father's Work

Area CodePhone Number
Emergency Contact Person (Other than Parent)
The emergency contact is contacted in the event that we are unable to contact the parents/guardians.
Name*

First NameLast Name
Home Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Relationship to Camper*
Should be Empty:

Health Information