EmailMe Form - 4th & 5th Retreat Registration

Child's Name *

First Last

Guardian's Name *

First Last

Guardian's Phone *

### - ### - ####

Guardian's Email *

Emergency Conact *

First Last

Emergency Contact
Phone Number *

### - ### - ####

Does your child have any allergies or medical conditions we should be aware of? *

Yes

No

Allergies/Medical conditions *

Are you willing to drop off your child by 4:45 p.m. on the 1st and pick up your child by 3:00 p.m. on the 2nd? *

Yes

No

Pay online for 4th & 5th Grade Retreat? ($65 per registrant) *

yes - 4th & 5th Grade Retreat online payment

no

Please note payments are processed through Paypal and there is a $1.75 fee for each registration.