2019 Youth Retreat Registration Form
Coordinated by Cornerstone Church of Virginia & Pilgrim Community Church
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BASIC INFORMATION
Thank you for joining us on retreat this year. Once the registration form is complete, a staff member will connect you to finalize your registration.
Registration Type *
As of 2018-2019 School Calendar Year
Full Name *
Email Address *
Phone Number *
School Name *
If graduated from higher education, please write "N/A"
Grade *
Shirt Size *
Church Affiliation *
Required
If you are not attending church, write your reasons for wanting to attend.
EMERGENCY CONTACT INFORMATION
Emergency contact must be over 18 years of age and must be the legal guardian of the student.
Contact Name *
Contact Phone Number *
Relationship *
Required
Registration
Early Registration Ends in the Month of May after which there is a $10 late fee.
Registrations after June incurs a late fee of $20.
No Registrations are received after July.
Registration Type
Payment Method *
Checks can be mailed to 4925 Twinbrook Rd., Burke, VA 22015. Students from Cornerstone & Pilgrim should pay through their churches.
SUBMIT
Thank you for joining our retreat! May God bless you through this journey in 2019.
Submit
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