I AM Senior High Youth Winter Retreat 2023

Please fill out this form and click submit.

I AM Senior High Youth Winter Retreat
Rock Mountain Bible Camp
Friday, February 24th - Sunday, February 26th
$175 per student | Additional $20 for T-shirt
T-shirt Deadline | February 10th 12:00am

Student Information

Name

Grade Level

Please select one option.

9 10 11 12

T-Shirt Size

Please select one option.

S M L XL XXL No Shirt

Address

Phone

This address will receive a confirmation email

Parent/Guardian Information

Parent/Guardian Name

Parent Cell/Primary Phone

Parent Work Phone

Parent Email

Parent Address (If different than the student)

Insurance Information

Insurance Company Name

Group Number

ID Number

Primary Subscriber Name

Insurance Company Phone

Permissions

Permission for Medical Treatment

Please select one option.

I do not wish my student to receive any medical treatment. In an emergency, Sparta EFC has my permission to obtain medical treatment for my c, call an ambulance, or transport my child to any available physician or hospital at my expense, with the following restrictions (If applicable)

Photography/Video Release

Please select all that apply.

I give permission for Sparta EFC to make non-commercial use of any activity photographs of my student.

IMPORTANT – PLEASE READ – HOLD HARMLESS RELEASE*

Please select all that apply.

I hereby grant permission for myself and/or child to participate in the Sparta Evangelical Free Church (SEFC) program noted above. I waive and release all rights and claims for damages against SEFC and their employees and agents for any and all injuries,

Signature

Please type your name here.

Payment

*There are two payment options!
Payment with T-shirt: $195
Payment without T-shirt: $175

Payment

WITH T-SHIRT ($195.00) NO T-SHIRT ($175.00)

Amount

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

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I AM Senior High Youth Winter Retreat 2023

Description

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