Equip Retreat 2019

Registration Options

Equip 2019 ($260.00)

Parent Name

Attendee Name

Parent Email

Phone Number

Address

Date of Birth

T-Shirt Size

Gender

Male
Female

Allergies - List any allergies to medication or other problems of which the adults in charge should be made aware - type NONE if your child does not have any:

Medications - List all medications currently being taken - type NONE if your child is not taking any:

Parental Consent Signature*

* I give permission for my child to attend the EQUIP 2019 Retreat. I understand that if my child is covered by health insurance coverage, that information must be shown below. Should the need arise; I give permission for my child to be taken to a doctor/hospital for medical treatment and authorize the holder of this form to consent to treatment. I hereby release and agree to indemnify EQUIP 2019, its agents, Woodland Christian Camp, and all affiliated church organizations from any and all liability for injury arising out of my child’s participation in this retreat. I have read the above, understand it fully, and sign it voluntarily. *

Church

Emergency Contact #1 Name

Emergency Contact #1 Phone

Emergency Contact #2 Name

Health Insurance Policy Number (Type None if none)

Emergency Contact #2 Phone

Health Insurance Provider (Type None if none)

Family Physician (Type None if none)

Physician Phone Number

Pastor

Church Address

Church Phone Number

Processing Fee

$10.00

Running Total

$10.00

Coupon Code

Total

$10.00

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