180 Youth Retreat 2023 - Registration/Health Form

Student Information

Name

Birthday

Age

Grade

Gender

Legal Guardian Information

Name

Home Phone #

Cell Phone #

Name

Home Phone #

Cell Phone #

Medical Information

Primary Care Physician

Primary Care Phone #

Medical Allergies

Food/Environmental Allergies

If you have any food allergies or dietary restrictions, please also fill out Gull Lake's Guest Dietary Request Form.

Prescription Drugs: If your student is on any prescription medications please list them on the lines below. Please send medications in original containers with name of drug and instructions clearly marked. Place medications in large plastic bag with student’s name marked on the bag. Medications will be given to student’s leader (except for emergency meds like inhalers, Epi pen, or insulin)

Please do not send your student with over-the-counter medications. (The Youth Team will have these meds available to students. This is in order to insure correct and safe use of medication.)

Non-Prescription Drugs: My student may be given over the counter medications like Tylenol, Ibuprofen, Benadryl, Tums etc.

Yes No

Any exceptions

Notes/special instructions for the Youth Leaders

Emergency Contact

In case of an emergency, please list emergency contact person(s) if other than legal guardian(s):

Name

Relationship

Home Phone #

Cell Phone #

Name

Relationship

Home Phone #

Cell Phone #

In case of a medical emergency or general medical care, I give consent for medical treatment for my student named above by authorized personnel. I certify that the above student has my permission to attend this retreat.

E-Signature of Parent/Guardian (I certify I am the legal guardian of the above-named student)

Payment $130.00

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

January 20-22

180 Winter Retreat at Gull Lake Ministries - January 20-22

Games, Food, Worship, & Challenges from God's Word.

Cost is $120 until January 4 and $130 after.

180 Youth Retreat 2023 - Registration/Health Form

Description

Please Fix the Following