July 14th – 17th at Refreshing Mountain – Transportation Provided455 Camp Road Stevens PA 17578Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name of Youth Participant *FirstLastDate of Birth *Last Completed Grade *5th6th7th8th9th10th11th12thAddress *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeGuardian EmailYouth Participant Phone#Emergency Conact Name *FirstLastEmergency Contact Phone # *Please List all Allergies – Food/Medication etc… *Is there any pertinent medical information that we should be aware of and/or reasons why this person may not fully participate in all retreat activitiesKnown Medical Conditions / Limitations *Is there any pertinent medical information that we should be aware of and/or reasons why this person may not fully participate in all retreat activitiesTerms and Conditions *I have read, and I understand and agree to all terms and conditions stated belowParental Permission : I hereby give my permission for my child ( Listed above on this form ) to participate in all activities of the 116 Youth Retreat. I agree to assume all risk of injury, harm, or damage to my child’s person or property. By signing this form, I give my full permission to seek emergency treatment of my child under the age of 18. I agree to indemnify and hold harmless all staff and participants from all liabilities, legal actions, damages, and claims of any kind or nature that may arise as a result of my child’s attendance at this retreat. By signing this permission slip, I understand the use of illegal drugs, beverage alcohol, the use of tobacco in any form, and/or weapons of any kind are strictly prohibited anywhere on the grounds or in any buildings/ vehicles. Any confiscation of and/or discovered use of the above mentioned items can result in the suspension of my child’s attendance at camp, I assume responsibility for any additional transportation arrangements or costs incurred as a result of this actions.Guardian Signature * Clear Signature DepositPrice: $20.00A $20.00 non-refundable deposit is required for attendanceHow would you like to pay for the deposit? *I’ll send my child with cashCredit CardStripe Credit Card *CardName on CardSubmit