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Youth Retreats

Please fill out the registration form below and click the "Submit" button to remit payment. If you do not wish to register online, you may also download a registration form at the bottom of the page.

The Fall Youth Retreat at Camp Laurelview is scheduled for November 15-17, 2013. Cost is $50/person. Deadline to register is November 13. 

Event starts on November 15 at 7:00 pm and ends November 17 at 10:30 am.

For all youth in grades 7-12.

    • Name *


    • Address *







    • Cell Phone Number



    • Camper Birthdate *

    • Name of Parent/Legal Guardian *

    • Current Grade *

    • Sponsoring Congregation Name (if applicable)

    • Parent Email

    • Camper Email

    • Camper Height

    • Camper Weight


    • Camper Info

    • Is the camper frequently subject to:












    • Has the camper had:












    • Please list camper allergies

    • Will the camper need to take medication(s) at camp? (Explain and list):

    • Camper diet restrictions?


    • Additional Information

      Please fill out as completely as possible.
    • Do you consider the camper to be:



    • Any emotional and/or behavioral concerns, or family circumstances which might affect the camper’s full participation?

    • Date of last tetanus immunization:

    • Camper physician name:

    • Physician phone number



    • Insurance name

    • Insured's name

    • Insurance group number

    • Insurance policy number

    • Emergency contact name:

    • Emergency contact phone number




    • Parent/Guardian permission

      In case of an emergency, I hereby give permission to the Camp Director to secure the proper treatment for my child, and I will assume financial responsibility for any services that are rendered necessary. I agree not to hold the Camp Director, staff, the Christian Church in PA, or the sponsoring churches responsible for any accident or illness that might occur to my child while attending camp.
    • Digital signature of parent/guardian: *

    • Date *


    • Camper and Parent/Guardian agreement

      For the health and safety of all campers: (1) Alcohol, illegal drugs, weapons, and other hazardous substances are banned from camp; (2) Campers are not permitted to smoke; (3) Campers who violate these rules will be sent home.
    • Digital signature of camper: *

    • Date *

    • Digital signature of parent/guardian *

    • Date *


    • Payment Information

      This form handles only one registration per camper. Please enter "1" in blank below. When finished, click the "Submit" button. You will be redirected to the PayPal site to complete your transaction.
    • Youth Retreat
       



NOTE: Do Not Alter These Fields:



Downloads

Title Date
Youth Retreat Registration Form
08/01/2012
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