AA United Youth Retreat 2016 (Feb. 12-14) Michindoh Conference Center, 4545 E. Bacon Rd. Hillsdale, MI 49242 Arrive at 6:00 p.m. on Feb.12, be picked up at 5 p.m. on Feb. 14

Student Information Name (First and Last)

Male | Female

Birthdate (Month/Day/Year)

6 7 8 9 10 11 12

Gender (circle one)

Street Address

Current Grade (circle one)

E-Mail Address (

City

State

Zip Code

Home Church I feel most comfortable speaking: (circle one)

)

Telephone Number

Youth Pastor/Leader (or Senior Pastor) English

Korean

Both

Other:___________

Student Agreement I agree to fully participate in all activities of the United Youth Retreat and will respect camp staff and property. I understand what is appropriate to bring and not to bring (which includes no drugs, alcohol, or tobacco products) and will follow the rules of the camp. I understand that engaging in inappropriate conduct means my parents and senior pastor will be notified and I will be sent home at their expense.

Youth Signature: __________________________________________ Date: ____/____/____

Medical / Emergency Contact Information (to be filled out by parents) Please list any medical conditions or special conditions to be watched for (i.e. allergies, dietary restrictions, fainting etc.): Please list all medications including dosages. (Please inform your pastor or director if your child needs special care.) (

)

(

Parents’ Names

Cell #

Additional Emergency Contact Name and Number

Family Physician Name and Number

Health Insurance Provider

Health Insurance Policy #

)

Work #

Signature releases the participating churches, the retreat staff/volunteers, and Michindoh Conference Center from any liability for any injuries/damages that may occur to the undersigned parent’s student on this retreat from Feb. 12-14, 2016. This also authorizes the retreat staff to take appropriate actions on behalf of the child including seeking medical attention in cases of emergency.

Parent’s Signature: _________________________________________ Date: ____/____/____ Enclose this form along with cash or check payable to your church. Turn in to your youth leader.