2022 Winter Retreat Registration Form (12/27-29)

You can now register multiple children in the same household.

Child #1 Name

Child #1 Date of Birth

Child #1 Current Age:

Child #2 Name

Child #2 Date of Birth

Child #2 Current Age

Child #3 Name

Child #3 Date of Birth

Child #3 Current Age

Legal Guardian's Name & Phone

Legal Guardian Email

This address will receive a confirmation email

Camper's Address

Child #1 Email

Child #1 Cell Number

Child #2 Email

Child #2 Cell Number

Child #3 Email

Child #3 Cell Number

Health Questionnaire

If you registered your child for our 2022 Youth Camps, then we already have the health & medical information on file and you can skip to Participation Consent & Emergency Contact Information

Please only complete the below section if:
1) Your child did not attend our 2022 Summer camps
OR
2) Your child's medical information has changed since June of 2022

I am filling out this section for: (Enter child's name)

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

Health Insurance? Yes No

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

Please enter anything else you need us to know here:

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(ren) to represent the Church in any and all activities. We also give consent for our child(ren) 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(ren)/ward(s) 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(s) 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(s).

Yes No

Retreat Fee is $35

Payment 0

I will pay via:

Online (enter $35 in above box) Cash or check at retreat Credit Card phone payment via headquarters, 816-461-7215 Check mailed to headquarters (700 W. Lexington, Independence MO 64050)

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2022 Winter Retreat Registration Form (12/27-29)

Description

Please Fix the Following