Registration:
PK Retreat (Aug 18, 2017 - Aug 20, 2017 )


PK Retreat is for students ages 12-19 whose parents are pastors, missionaries, or credentialed ministers.  Retreat is free if registered by July 28.  After July 28, fee will be $25.00

Please remember to click on the "CHECKOUT" button after you register. You will receive a confirmation email after you have completed registration.  IF YOU DO NOT RECEIVE A CONFIRMATION EMAIL AFTER REGISTERING, YOUR REGISTRATION DID NOT GO THROUGH!

USER INFORMATION
First Name:
Last Name:
Name child goes by (if different than above):
Gender:
Male  Female  
Birthdate:
   
Age:
Address:
City:
State:
Zip:
Parent/Guardian(s) Name:
Phone ### - ### - ####:
Cell/Emergency Phone ### - ### -####:
Email:
Confirm Email:
Church City/Name:
Desired Roommates (Some rooms may require sleeping on a mattress on the floor)
Roommate #1:
Roommate #2:
Roommate #3:
Roommate #4:

Health Questionnaire and Permissions (Read Carefully)

This health questionnaire is for the benefit of the camp first-aid administrator and physician in case of illness or accident. Camp registration includes secondary accident insurance (not illness) during camp. (This insurance covers campers only in the event they are not covered by another policy.)

I have medical insurance coverage for my child.:
Yes  No  
Are all immunizations current with state law?:
Yes  No  
My camper may be given over-the-counter, non-prescription medications or applications, not to exceed recommended dosage, for stomach discomfort, burns, cuts, insect bites, rash, aches, fever, cough, congestion, etc.:
Yes  No  
Does Camper have:
Heart Trouble
Seizures
Asthma
Hernia
Diabetes
HIV/AIDS
Lung Trouble
Allergies
Other
Please explain checked items AND list any medications (name/dosage/instructions) the camper is taking:
All medications, prescriptions and over-the-counter drugs MUST BE BROUGHT IN THE ORIGINAL BOTTLE to the Camp Nurse upon arrival at camp. Medications such as Tylenol, Ibuprofen, Bendryl and anti-itch creams do not need to be sent with the camper. Please provide additional information if necessary.

(Signature of Legal Parent or Guardian and relationship to this child required. Typing your name here serves as your digital signature for this registration.)

In submitting an application, all campers agree to abide by all camp rules, maintaining a Christian spirit of cooperation at all times.

Digital Signature:
Student's first year to attend PK Retreat?:
Yes
No
Parent Ministry Position:
Enter the Security Code:
I agree to the terms and conditions:
Read Terms & Conditions