Midwinter Youth Retreat: Adult and Post-High Form

Please complete all sections of this form and indicate method of payment.  If you are mailing a check, please send it by
Jan. 31 to Christian Church in WV, 1402 Washington Ave., Parkersburg, WV  26101.  

If you have questions, please call 304-428-1681.

Name

Address
including
City, State & Zip

Primary Phone
(include area code)
Secondary Phone

Email

Gender

Congregation City:

Congregation name:
Female
Male
BACKGROUND INFORMATION AND RELEASE  PERMISSION STATEMENT
By checking the box below, I declare that I have never been convicted of a felony.  I give my permission to the
Christian Church (Disciples of Christ) in West Virginia through its Department of Christian Formation to contact
persons and organizations to determine that my abilities and character are appropriate for leadership in Church
youth programs.  This indicates my permission for such action, and also gives permission for photographs and
moving images of me to be published by any means to the Christian church (Disciples of Christ) in West
Virginia.
I understand, also, that I must submit a written, signed Health Form prior by the beginning of the event.
Permissions granted as stated above
PAYMENT INFORMATION
(Please check one):

A check will be mailed (by 1/31) for $100 to
the Christian Church in WV

My congregation will send payment..

I will make payment electronically.
(A link for electronic payment will be sent
via email after this form is processed)
All set?  Click "Submit".  A confirmation
note will be sent by email within 1 week.