Winter Retreat Leader Sign Up

Leader Sign-Up Form 2025 for Leaders

* Indicates required field

Youth Leader Name *

First

Last

Email *

cell Phone Number *

Date of birth (MM/DD/YYYY) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Have you been on a retreat with us before? *

Yes Not yet

Are you 21 or older AND willing to drive students if needed? *

Yes No

If yes, how many seats do you anticipate having for people (not including you) in your vehicle? *

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

what's one of your favorite snacks, coffee, drink, or treat? *

Any other important info we should know? *

Are you excited?? *

By checking the box below, I, the participant, do hereby authorize Grace EC Church, acting as the participants agents, to consent to any x-ray, examination, anesthetic, or surgical diagnosis, or treatment and hospital care or service, which is deemed advisable and is rendered under the general or specific diagnosis, treatment, or hospital care which the above mentioned physician, may exercise his/her best judgement, may deem advisable. I hereby authorize any hospital which has provided treatment to the participant to Grace EC Church upon completion of treatment. These authorizations shall remain effective through the below period unless sooner revoked and delivered to Grace EC Church. I release Grace EC Church from all liability connected with my participation in these activities. I acknowledge that participating in these activities is of my own choice and assume all risk in connection thereto. Grace EC Church reserves the right to use any audio, video, and/or photography of attendees from any retreat activities. Youth Ministry-Related event: Winter Meltdown at River Valley Ranch on the dates of January 17 through 19, 2025. *

I agree

let's go!!

Leader Retreat Form

Grace Church Kutztown

Leader Retreat Form

Grace Church Kutztown​

Grace Church Kutztown