Winter Retreat Registration Form

Youth's Name

Youth's Date of Birth

Youth's Current Age:

Current Grade

Legal Guardian's Name & Phone

Legal Guardian Email

This address will receive a confirmation email

Youth lives with...?

Mother Father Both Parents Other

Youth's Address

Youth's Email

Youth's Cell Number

Is the youth a Remnant Church member?

Yes No

Home Congregation:

What t-shirt size do you need?

Health Questionnaire

List any allergies the camper has (Example: Penicillin, Sulfa, Latex, Peanut Butter, Bee Stings, etc.)

List any Medications the Camper currently takes, dosage and frequency (medications must be in original Rx bottle for camp nurse to administer)

Medical History Other (include surgeries)

Date of Last Tetanus Shot:

Immunizations Current?

Yes No

Participation Consent & Emergency Contact Information

Emergency Contact Name, Relationship & Phone (in case legal guardians cannot be reached):

Please type your name to serve as electronic signature for acceptance to this waiver: We, the undersigned parents/guardians consent for our above named child to represent the Church in any and all activities. We also give consent for our child to be transported to said activity and will not hold The Remnant Church of Jesus Christ of Latter Day Saints responsible in case of accident or injury while en route to or from said activity. We hereby agree to hold the Church, its employees, agents, representatives, leaders and volunteers harmless from any and all liability, action, causes of actions, debts, claims or demands of every and any kind and nature whatsoever which may arise by or in connection with participation by my child/ward in any activities related to the activity titled above. If we cannot be reached and in the event of emergency, we also give our consent for the Church, sponsors, or leaders to obtain through a physician or hospital of its choice, such medical care as is reasonably necessary for the welfare of the individual if he/she is injured in the course of the activity of The Remnant Church of Jesus Christ of Latter Day Saints titled above.

Today's Date:

I hereby certify that I am at least 18 years of age and acting as legal guardian for registered youth.

Yes No

Health Insurance?

Yes No

Health Insurance Co., Policy Number, Group Number, and Legal Guardian who carries the insurance:

Payment

I will pay via:

Mail payments should be sent to:

Remnant Church of Jesus Christ of Latter Day Saints

Attn: Camp Registration

700 W. Lexington

Independence, MO 64050

Phone payments may be made during regular business hours at 816-461-7215

Winter Retreat Registration Form - 2021

Description

Winter Retreat Registration Form - 2021

Description

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