Middle School Retreat October 19-21, 2018
Lake Williamson, Carlinville, IL Open to all 6th - 8th grade students Deadline to Register—October 7, 2018
Registration Fee: $149 (includes lodging, meals, transportation) Student Information
(Please Print)
If student has already registered for CORE for the 2018-2019 year, you are only required to enter their name, birth date and t-shirt size on this form, sign below, and return it with their medical release form and payment.
Student Name: _________________________________ Birth date: ____ / ____ / _________ (mm/dd/yyyy) Street Address: _________________________________ Gender
M
F
City & Zip: _____________________________________ Main/Home Phone: _________________________ Student Cell Phone: ____________________________ Cell Phone Carrier (ie. Verizon): ________________ Grade: 6
7
8
Shirt Size (Adult Sizes): S
M
L
XL
Allergies/special needs: Please describe here or call Pua at 636.779.2361 to discuss.
_________________________________________________________________________ _________________________________________________________________________ Parent 1 Information:
Parent 2 Information:
Name: ____________________________________
Name: ____________________________________
Cell Phone: ________________________________
Cell Phone: ________________________________
Email: ____________________________________
Email: ____________________________________
Parent Permission (Required) The registrant has my permission to participate in St John Student Ministry Middle School Retreat, Oct. 19-21, 2018. I understand when participating in St John Student Ministry activities, the registrant may be photographed for print, video, or electronic imaging. I understand the images may be used in promotional materials for St John Church. I acknowledge the images will be the sole property of St John Church. ________________________________________________
Signature of Parent/Guardian
_________________
Date
To Register Return: 1) completed registration form 2) medical release form 3) copy of insurance card 4) fees Payment can be made by check (made payable to St. John Church) or with a credit card online at www.stjstl.net/open-registrations.
Mail or drop off your registration at the church office. St John Church 15800 Manchester Rd, Ellisville, MO 63011 Attn: Pua Coffman-Retreat
Retreat registration fees are non-refundable after October 1. Additional information about the Middle School Retreat, and other Student Ministry programs can be found at www.stjstl.net/students
Questions?
Contact Pua Coffman
[email protected] 636.779.2361 Office Use Only
Date ____________________ Pd __________________ Credit ______Cash______ Check ________________