Spring Retreat 2023

Parent/Guardian Information

Name

This address will receive a confirmation email

Phone

Address

Name of Emergency Contact

Emergency Contact Number

Is sponsor authorized to approve medical treatment?

Yes No

Student #1

After you fill out each one of your students information there will be a payment option at the end of each one. You can choose to pay with credit card or turn in cash/check make checks out to Crossroads Church of God.

Name

T-shirt Size

Insurance Provider

Policy Number

Group Number

Please list any food, medical or other allergies your student has:

Please list any medication your student will have on this trip and how often they will need to take it:

Please note anything else we might need to know about your student

Registration Fees

Additional Siblings

If you have 2 or more siblings going on the trip, fill out the information below if different than what is listed above for each sibling.

Sibling #2

Name

T-shirt Size

Insurance Provider

Policy Number

Group Number

Please list any food, medical or other allergies your student has:

Please list any medication your student will have on this trip and how often they need to take it:

Please note anything else we might need to know about your student:

Registration Fees

Sibling #3

Name

T-shirt Size

Insurance Provider

Policy Number

Group Number

Please list any food, medical or other allergies your student has:

Please list any medication your student will have on this trip and how often they need to take it:

Please note anything else we might need to know about your student:

Registration Fees

Sibling #4

Name

T-shirt Size

Insurance Provider

Policy Number

Group Number

Please list any food, medical or other allergies your student has:

Please list any medication your student will have on this trip and how often they need to take it:

Please note anything else we might need to know about your student:

Registration Fees

Participation Agreement

By typing your name below, the participant (or parent/guardian if participant is a minor) acknowledges and accepts the risks of physical injury associated with participation in the activity described above. Except for gross negligence on the part of the sponsor, the participant (or parent/guardian) accepts personal financial responsibility for any bodily or personal injury sustained during the activity. Further, the participant (or parent/guardian) promises to hold harmless the sponsoring organization and its representatives for any injury related to the activity. If dispute over this agreement or claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable arbitration process.

Name (participant or parent/guardian if participant is a minor)

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Spring Retreat 2023

Description

Please Fix the Following