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.
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.
Zip Code. ( ). Telephone Number. Home Church. Youth Pastor/Leader (or Senior Pastor). I feel most comfortable speaking: (circle one). English Korean Both ...
English Korean Both Other:______ ... what is appropriate to bring and not to bring (which includes no drugs, alcohol, or tobacco products) and will follow the.
If you have more than one child attending, take $10 off each registration...so it would be $85 for a single session per child, or $155 for both sessions per child. Questions? Email Coach Tufts at [email protected] or call/text at 503-830-2147. Ca
Application Requirements: ⢠Graduate from high school between July 1, 2017 and June 30, 2018. ⢠Documented superior academic proficiency. ⢠Recognition for notable achievement in mathematics and/or science. ⢠Skills and achievements outside o
Application Requirements: ⢠Graduate from high school between July 1, 2017 and June 30, 2018. ⢠Documented superior academic proficiency. ⢠Recognition for notable achievement in mathematics and/or science. ⢠Skills and achievements outside o
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Mail to: Attn: Luke Durbin. North Ridgeville High School. 34600 Bainbridge Road. North Ridgeville, OH 44039. Early registration deadline is Friday, May 26. th.
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Trends in Youth Internet Victimization Findings From Three Youth Internet.pdf. Trends in Youth Internet Victimization Findings From Three Youth Internet.pdf.
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