2021 Fall Retreat Registration.
Please fill out this form and click submit.
Parent 1 Name
*
Parent 1 Email
*
This address will receive a confirmation email
Parent 1 Phone
*
Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Camper 1 Information
Name
*
Gender
*
Please select one option.
Male
Female
Grade currently attending (2021-2022)
*
Please select one option.
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Select Option
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Retreat Selection
*
Please select all that apply.
3rd - 5th Grade Retreat Oct 15-16
6th - 12th Grade Retreat Oct 22-23
Payment
Retreat Price ($65)
Other ($0)
Retreat Price ($65)
Other ($0)
Amount
Additional Items
No selection ($0)
Water bottle ($5)
Snack Shack Account ($10)
No selection ($0)
Water bottle ($5)
Snack Shack Account ($10)
Amount
T-shirt Size
*
Please select one option.
Youth Small
Youth Medium
Youth Large
Youth X-Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
Adult XXX-Large
Allergies?
Camper 2 Information
Name
Gender
Please select one option.
Male
Female
Grade currently attending (2021-2022)
Please select one option.
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Select Option
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Retreat Selection
Please select one option.
3rd - 5th Grade Retreat Oct 15-16
6th - 12th Grade Retreat Oct 22-23
Payment (If registering 2 campers, remember to select the retreat price here.
Other ($0)
Retreat Price ($65)
Other ($0)
Retreat Price ($65)
Amount
Additional items
No Selection ($0)
Snack Shack Account ($5)
Snack Shack Account ($10)
No Selection ($0)
Snack Shack Account ($5)
Snack Shack Account ($10)
Amount
T-Shirt Size
Please select one option.
Youth Small
Youth Medium
Youth Large
Youth X-Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
Allergies?
Credit/Debit Card Number
Expiration Date/CVC
Name on Card
Card Billing Address
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Submit
Description
Please fill out this form and click submit.
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