July 14th – 17th at Refreshing Mountain – Transportation Provided
455 Camp Road Stevens PA 17578

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Name of Youth Participant
Address
Emergency Conact Name
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 activities
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 activities
Terms and Conditions
Parental 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.
Clear Signature
Price: $20.00
A $20.00 non-refundable deposit is required for attendance
How would you like to pay for the deposit?