Retreat - Registration

Teen's First Name

Teen's Sex

Female

Male

Teen's Grade

Home Address

Teen's Last Name

Teen's Date of Birth

City, State and Zip

What parish are you registered at?

Mothers Name

Fathers Name

Parent's Primary Email

Emergency Contact Name

Mothers Phone

Fathers Phone

Parent's Secondary Email

Emergency Contact Phone

List Medical Conditions or Special Considerations for teen

List any Allergies for teen

List any Medications/Dosage for teen

List any Custodial Issues we should be aware of

I accept the liability release policy. ( Required )View policy here

I accept the permission to seek emergency care policy. ( Required )View policy here

I accept the media release policy. ( Not Required ) View policy here

I accept the permission to contact youth policy. ( Not Required )View policy here

Select an item ($)

Fall Retreat - Registration - $215

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