Registration Form


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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 ________________