EmailMeForm
SR. HIGH RETREAT REGISTRATION
** REGISTRATION IS FULL. Fill out this form to join waitling list. We will be in touch if space opens up. **
Smith Mountain Lake
at Mark and Kendra Shickel's and Dennis and Donna Houff's
Friday-Sunday, October 4-6, 2024
Cost is $30
Registration deadline is Monday, September 30
Meet at the church Friday at 5:00 p.m. and return Sunday around 3:00 p.m.
Complete this form, click submit, pay by credit card, OR if you'd like to pay by cash or check just close out of your browser. You're all done with this form!
If you're paying by cash or check, bring cash to the church office, or bring/mail check to the church office (make check payable to Covenant Pres. Church, mail to 32 Southgate Ct., Ste. 101, Harrisonburg, VA 22801).
You'll receive a confirmation email that will include what to bring.
Student Name(s)
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Address
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Phone
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Student Email
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Parent Email
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Total student(s) registered at $30.00 each:
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Please select
1
2
3
4
Amount to donate for scholarships:
$
Dollars
.
Cents
Late arrival
I'll be arriving late & providing my own transportation.
Health Insurance Provider
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Policy #:
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Any allergies and/or medical needs?
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Emergency Contact:
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Phone # of Emergency Contact:
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PLEASE READ, SIGN & DATE
I/We understand that there are inherent risks involved in any ministry or athletic events; and I/we hereby release Covenant Presbyterian Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child(ren)'s involvement. In the event that he/she is/are injured and require the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that I/we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the child(ren) named above. I/We also agree to bring my/our child(ren) home at my/our own expense should he/she become ill or if deemed necessary by the youth ministries staff member. This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Covenant Presbyterian Church and its staff of any liability against personal losses of my/our child(ren). I/We, the undersigned, have legal custody of the child(ren) named above, a minor(s), and have given my/our consent for him/her to attend the HIGH SCHOOL RETREAT on Friday-Sunday, October 4-6, 2024.
Parent Signature
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Clear
Parent Signature
Clear
Date
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Total
$0.00
