Winter Retreat Student Signup

If you are interested in signing up for our youth retreat, please fill out the form below. If you have more than one student, you will need to fill the form out for each student that wishes to attend.
Retreat Dates: January 17 - 19, 2025.
Sign Up Form and $50 Deposit due November 17, 2024.
Full payment due by December 16, 2024.

* Indicates required field

Name of Parent/Guardian filling out this form: *

First

Last

Parent/Guardian Email *

Home Address *

Student Name *

First

Last

Student Date of Birth (MM/DD/YYYY) *

Has your student attended a retreat with us before? *

Yes Not yet!

Grade student currently in *

Emergency Contact #1 Name *

First

Last

Emergency Contact # 1 Relationship to Student *

Emergency Contact #1 Phone Number *

Emergency Contact #2 Name *

First

Last

Emergency Contact #2 Relationship to Student *

Emergency Contact #2 Phone Number *

Is your student allergic to anything? *

Does your student take any medications that they will be bringing with them to the retreat? This includes any vitamins, over the counter, or prescription medications. *

Yes No

If Yes, list any current medications (including medication name, dosage, and times) for any medications they will be bringing with them *

Can your student keep the medication in their possession or would you like one of the adult leaders to keep it in their possession for the weekend? *

My student may keep their medication in their possession. I would like one of the adult leaders to keep my students medication for the weekend.

My student may require reminders of when to take their medication. *

Yes, please remind them.

Please list any other pertinent health information that it may be helpful for the adult leaders to know. *

If you are unable to pay the full cost of the retreat ($190) for your student, please enter how much you are able to pay towards the total. A minimum of the $50 deposit is required to reserve the spot. If financial aid is requested, one of the youth leaders will be in contact regarding this after the form is received. *

PLEASE INCLUDE THE FOLLOWING INSURANCE INFORMATION: Policy holder's name, insurance company name, claim officer address, policy identification number *

By checking this box, I acknowledge that the weekend will be a cell phone and electronic device free weekend for our students and that me and my student are aware of this. If for any reason your student would need to have a device with them for the weekend or if you have any questions, comments, or concerns about this, please note them in the next box and one of the youth leaders will be in contact regarding this. All adult leaders on the trip will have their cell phones on them the weekend of camp and can be reached if needed for any reason during the weekend or you can call the main office at RVR. All of these phone numbers will be made available to you before the weekend of camp in case they are needed. *

Me and my student agree.

Please note any questions, comments, or concerns regarding the device free weekend here and a youth leader will be in contact. *

This health information is correct as far as I know, and the student listed has permission to engage in all camp activities except as noted by me. I give permission for the group leaders that take my child on the youth retreat to River Valley Ranch to provide ongoing health care/first aid to my student and to select local medical personnel to order tests and treatment as needed. The leaders will make effort to reach any emergency contacts if needed, in the event that the emergency contacts/guardians cannot be reached in an emergency, I hereby give permission to the physician selected by the group leaders to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for the student listed. I, the parent/guardian of 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 or specific supervision of any licensed physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being rendered, but is given to provide authority and power on the part of Grace EC Church to give specific consent to any and all such diagnosis, treatment, or hospital care which the above mentioned physician, the exercise of his/her best judgment, may deem advisable. I hereby authorize any hospital which has provided treatment to the participant to surrender physical custody of the participant to Grace EC Church (Amory Mumbauer, Eric Dieterly, or McKenzie Eberly) upon completion of treatment. These authorizations shall remain effective through the period below unless sooner revoked and delivered to Grace EC Church. I hereby authorize my student to go to this Youth Ministry-Related event: Winter Meltdown at River Valley Ranch on the dates of January 17 through 19, 2025. This authorization shall remain effective throughout the designated time frame unless sooner revoked and delivered in writing and delivered to Grace EC Church. I release Grace EC Church from all liability connected with my child’s participation in these activities. I acknowledge that participating in these activities is their choice and assume all rise in connection thereto. Grace EC Church reserves the right to use any audio, video, and/or photography of students from any of the retreat activities. I allow them to be transported in a vehicle with one of the approved Grace Church Youth Leaders attending the trip. *

I agree.

If your student has any minor aches or pains while we are at the retreat, do you give permission for one of the Grace Church youth leaders to give them medication if needed? *

I give consent for my student to be given Tylenol/Motrin for minor aches or pains should they occur. I do not give consent for my student to be given any medication without their Emergency Contact #1 being called first.

Digital Signature of Parent filling out form (please type out your name) *

First

Last

Digital Signature Date (MM/DD/YYYY) *

Click Here to Submit Your Form

Youth Retreat 2025
Sign-up Form

Grace Church Kutztown

Youth Retreat 2025Sign-up Form

Grace Church Kutztown​

Youth Retreat 2025
Sign-up Form

Grace Church Kutztown