Midwinter Youth Retreat:  Youth Registration Form
YOUTH:  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.  

You must bring a printed and signed copy of the health form to the event, and read the welcome letter from the
Associate Regional Minister carefully, which may be downloaded here.

ADULTS & POST-HIGH PARTICIPANTS: Please skip to this page.

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

Name

Address
including
City, State & Zip

Home Phone (with area
code)
Parent's Work/Cell
Phone (incl. area code)
Email

Gender

Congregation City:

Congregation name:

Parent's Email:
Student's Cell Phone
Female
Male
 Grade:
Age
Date of
Birth:
BACKGROUND INFORMATION AND RELEASE  PERMISSION STATEMENT
By checking below, I agree to the standards of conduct:
  • I will not possess nor use alcoholic beverages, tobacco products, or non-prescription drugs in any quantity during the Retreat.
  • I will give any prescription drugs and directions for administration of the prescription drugs to the Director for safe keeping during the Retreat.
  • I will not drive any motor vehicle during the event during the event unless permission is given by the Director.  Youth participants will leave their
    vehicle keys with the Director upon arrival and receive them back when they depart.
  • I will co-operate with the leadership and support the program of the Mid-Winter Youth Retreat.
  • I understand that I will be dismissed from the event and the grounds where it is being held immediately if I am found in violation of these
    standards.  Furthermore a statement will be placed on file with the Christian Church (Disciples of Christ) in West Virginia indicating that I will not
    be permitted to participate in any future Regional events unless I indicate in a written petition that I will abide by these Standards.
I agree as stated above, and understand that all signatures (including parent and minister)
on the Health Form and Registration will be completed and mailed or brought to the event.
PAYMENT INFORMATION
(Please check one):

A check will be mailed (by 1/31/11) for $100
to the Christian Church in WV.

My parent will make payment electronically.
(A link for electronic payment will be sent
via email after this form is processed)

My congregation will be sending payment.
All set?  Click "Submit".  A confirmation
note will be sent by email within 1 week.