Valley Revival Youth Retreat Registration

Parent/Guardian Name(s)

This address will receive a confirmation email

Phone

Address

Date

Name of Retreater(s)

Grade/Age

Health Card #

Emergency Contact Name

Emergency Contact Phone Number

Allergies

Medications

Special Diet Requirements

Yes No

If yes to the previous question, please specify.

Youth Group

Is your child interested in playing in the 3 on 3 Basketball tournament?

Yes No

Do you give permission for photos/videos of your child(ren) to be used for promotional purposes?

Yes No

Payment Options and Cost: $50.00

E-transfer (Send to treasurer@salemchurch.ca and please include in the comments retreater name and Valley Revival Registration.) Cheque (Send your cheq to Box 303 Waldheim SK, S0K 4R0 please make cheq payable to Salem Church and in the memo include retreater name and Valley Revival Registration.) Cash (Send to Salem Church Box 303 Waldheim SK, S0K 4R0 Please include a note specifying this is for Valley Revival Registration included with the retreater name.)

Liability Waiver: The Parent/Guardian of the participant recognizes the potential risks associated with participating in this Youth Retreat and agrees to release Salem Church, its employees and volunteers from any liability associated with injury to the participant or damage to the participant's belongings.

I agree

Questions/Other Comments

Valley Revival Youth Retreat Registration

Description

Please Fix the Following