Winter Retreat, '25 Registration

Student Information

First Name

Last Name

Gender

Birthdate

Grade

Phone Number

Parent Email

Financial Information

Registration: Deposit ($40)

I understand that the deposit of $40 will need to be paid to Pastor Zach before my spot is reserved.

Yes

No

Registration: Full Cost ($80

I understand that the full amount of $80 (which includes the $40 deposit) will need to be paid to Pastor Zach by the registration cut off date on Jan 12th for me to attend.

Yes

No

Student Medical Information

Please list all medical conditions

Please list current medications being taken

Please list all restricted activities

Does the participant have any allergies?

Yes

No

Allergies

Please list any allergic reactions you may have:

Date of last tetanus shot (at least provide year)

Is the 1Eighty Leaders authorized to provide medical treatment if necessary?

Yes

No

Please contact parent first

Is the participant covered by medical insurance?

Yes

No

Please provide the name of your medical insurer:

Please provide the Policy or Group Number for the participant's insurance:

Medications

By checking below, I hereby give permission to the Berwick Assembly Youth Staff and Volunteers to administer any of the following over-the-counter medications to my student as needed in the dosage appropriate based on age and size.

Note: For the safety of all students, any medications, prescriptions and over-the-counter drugs should be in original packaging with written dosage & administration instructions.

Emergency Contact Information

Emergency Contact Name

Relationship to the Student:

Cell Phone Number

Home Phone Number

Work Phone Number

PennDel Medical Release Form

For your student(s) to participate at Winter Retreat they must fill out this medical release form

Click here to fill out the medical release

Please indicate that you have filled out the medical release

I have filled out the medical release

I have not filled out the medical release

Parents & Student Agreement

Parent:

I hereby give permission for my child to attend this event as indicated above. I further certify that this health history is correct as far as I know and the person herein described has permission to engage in all prescribed activities, except as noted.

IN CASE OF EMERGENCY, I hereby give permission to the physician selected by Berwick Assembly to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for my child. I also hereby give permission to the members of the Youth Staff and Volunteers to inspect the contents of any or all of my child's personal belongings, and to withhold and/or dispose of any improper or illegal contents.

By including my name below, I acknowledge that I have read and agree to the aforementioned authorizations

Please choose today's date:

Student:

I understand that I am expected to conduct myself in a manner that represents Jesus well during this trip. I will not wander off by myself. I will not bring any tobacco, vapes, knives, or any other weapons with me on this trip. My language will be both appropriate and God-honoring. I will respect the 1Eighty leaders at all times.

By including my name below, I acknowledge that I have read and agree to the above regulations

Today's date:

Final Memorandum of Understanding

I understand that because I am completing an online registration form, I will be accountable for the submission of the registration fee of $80 as indicated above

Yes

No