2026 Zion Hill Youth Retreat
September 18-19, 2026 (Grades 6-12) $60
Personal Information
Participant Type
*
Please Select
Camper
Youth Volunteer
Name
*
First Name
Last Name
Gender
*
Please Select
Male
Female
Date of Birth
*
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Grade
*
Please Select
6
7
8
9
10
11
12
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Amount Owing
Home Church
Desired Roommate
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Next
Medical Information and Emergency Contacts
Health Card #
*
Family Physician and Phone Number
First Aid
*
Please Select
Yes
No
I give permission for the medications outlined on the registration form to be administration to my child by the first aid attendant of Zion Hill
Medical Aid
*
Please Select
Yes
No
In the case of medical emergency, I understand that effort will be made to contact the primary contact or the emergency contact. In the event they cannot be reached, I hereby give permission for the camp director/designate to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant.
Persons Authorized to pick up campers:
*
Current Problems
*
None
Bowel Problems
Stomach Aches
Headaches
Nightmares
Sore Throats
Ear Infections
Bedwetting
Homesickness
Sleepwalking
Frequent Colds
Sinus infections
Other
Medications/Creams
*
Medical Conditions
*
None
ADD/ADHD
Behavioural disorder
Convulsions
Asthma
Hearing Problems
Seizures
Diabetes
Other
Does your child have allergies?
*
No
Yes, Please fill in details below
Allergies/Sensitivities
*
Will your child have medications at Zion Hill?
*
No
Yes, Please fill in details below
Medications
*
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Consent and Authorization
Payment Email
example@example.com
I consent to the taking and reasonable use of videos and photography of my child named above during Zion Hill Camp. I hereby authorize that these may be only used for the following purposes (select all that apply):
*
Special Instructions and Other pertinent information
Please outline any special instructions concerning care, medication, diet, allergies, custody, etc.
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Signature
*
Submit
Should be Empty: