Young Adult Retreat Registration

Young Adult Discipleship Weekend Registration Form

Registration Type

Please select your registration type. Payment can be sent via mail to Oakes Church of the Nazarene Attention: YA Retreat 1019 Ivy Ave, Oakes, ND 58474

Participant Information

Name

First Name

Last Name

Church

Select your church

Email Address

Phone

(###)

###

####

Birthday

YYYY

Gender

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Extra Activities

Please select which activities you are likely to participate in for planning purposes.

Chunky Blanket Class (materials provided $15 extra charge)

Gym Games (Basketball, Volleyball, Dodgeball etc)

Board Games

Visit Lovelace Farm (Goats, chickens, dogs)

Marital Status

Spouse name (if applicable)

Spouse Phone (if applicable)

(###)

###

####

Extra Activities

What activities would you like to participate in?

Blanket Making (supplies provided - $15 extra charge)

Visiting Farm Animals

Board Games

Gym Games (volleyball, basketball etc.)

None

Emergency Contact Information

Name

First Name

Last Name

Relationship

Phone

(###)

###

####

Medical Information

Allergies:

Medications:

Physical/Mental Impairments:

Any other pertinent facts to which a physician should be alerted:

Insurance Company

Insurance Policy Number

Release of All Claims

I hereby approve the application, certify its correctness and expressly wave any and all claims against the Prairie Lakes Church of the Nazarene NYI, any of its District Boards, and its representatives because of any injury or other damage that may have incurred to me or my property in connection with or incident to or travel to or from the Prairie Lakes NYI retreat and related events. Permission is hereby given for images of retreat experiences that include my likeness to be used in promotions of retreat activities. IN CASE OF MEDICAL EMERGENCY: I hereby give permission to the physician selected by the staff to secure proper treatment of myself for and to any injections, hospitalization, anesthesia, or surgery for myself as named on this form.

Participants Signature