Silver Birch Fall Retreat - Middle School 
Digital Sign Up & Parent Contact Form
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Silver Birch Fall Retreat 
Place:       Silver Birch Ranch (N6120 Sawyer Lake Rd. White Lake, WI 54491)
Date:         Friday, Oct. 13 - Sunday, Oct. 15, 2023
Time:        Bus leaves Gibbsville Church on Friday at 3:30pm 
                     We’ll be back Sunday afternoon around 12:30pm    
Cost:         $102 Venmo payment @gibbsvillechurch 
                                                         OR  
                     $100 cash/check made out to "The Well - MS" 
Sign Up:  Sign up and payment are due on Monday, October 2nd.  

I understand that the event will take place at Silver Birch Ranch in White Lake, WI. I understand that while there my son/daughter may be exposed to/participate in all the experiences associated with northern Wisconsin camping & retreating including but not limited to: horseback riding, paintball, basketball, sports & field games, swimming, canoeing/boating, hiking, zip-lining, rock-wall climbing, worship and spiritual growth opportunities.

Should an accident or injury of any kind occur while my son/daughter is participating, I release each church represented at the retreat, along with their pastors, boards, directors, leaders, sponsors and all additional adult chaperones on the trip from any responsibility or liability for the accident or injury and from any claim for damages from the accident or injury. In the event that emergency medical treatment is required, I give my permission to the adult leaders/chaperones to secure needed medical treatment for my son/daughter and I give qualified medical personnel permission to provide treatment.

I understand that neither Silver Birch nor any church represented at the retreat is responsible for any charges incurred during emergency medical treatment and that I, myself, as parent or legal guardian, am solely responsible.
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Student's First & Last Name *
Student's Grade  *
Student wears an adult shirt size  *
Student's Date of Birth *
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Student's Home Address *
Emergency Contact Name & Phone Number (Parent/Legal Guardian)  *
Secondary Emergency Contact Name & Phone Number *
Please list any medical conditions, allergies, or necessary medications
Please list any special dietary needs
If you are paying through Venmo - please send $102 to @gibbsville church

Copy and paste the url below:
https://account.venmo.com/u/gibbsvillechurch

Payments may also be made via cash or check! Please make checks out to "The Well - MS" 
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Parent/Guardian Digital Signature - In typing my name I am giving my digital signature that the information provided is true to the best of my knowledge. *
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