Fall Youth Retreat Registration

Middle and High School youth are invited to join us as Pastor Miranda West helps us to go "BEYOND" — we’ll explore what it means to go further in our faith, reach higher in our calling, and discover what lies beyond the limits we set for ourselves.

The cost for this event is $125.( that includes lodging for 2 nights and meals)

Check in Time: 8p.m. Friday September 19th

Check Out Time : After worship starting at 10:30a.m on Sunday September 21st.

CAMPER INFORMATION

Camper's Full Name *

Preferred Name or Nickname *

Pronouns *

Phone Number *

Camper Email *

Date of Birth (Month/Day/Year) *

Will you have an Adult Chaperone joining you? If yes what is their full name? *

EMERGENCY CONTACT and MEDICAL INFORMATION

Does the Camper have any allergies? (YES - please list allergies, or NO) *

Does camper have any medical conditions or restrictions? Please explain.

I give permission for camper to receive over the counter medication ? *

PARENT/GUARDIAN INFORMATION

Parent / Guardian Name? *

Relationship to the camper? *

Best Phone Number to reach you? *

Parent/Guardian Email *

Home Address? *

PERMISSIONS

Do you give permission for your child to be photographed or recorded during youth activities, with the understanding that images may be used in print, online, or social media *

I understand that participation in youth activities may involve some risk. By signing this form, I release and hold harmless The Florida Disciples Regional Church and The Retreat At Silver Springs, its staff, and volunteers from any liability for accidents or injuries that may occur. ( Please type your name and the date) *