Fishersville UMC Students 2022 Winter Retreat Permission Form

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Friday, February 25 - Sunday, February 27

Drop-Off: 2/25 5:00 PM
Pick-Up: 2/27 1:30 PM

Please see Retreat Signup Packet for full details of itinerary, packing list, scholarship application, rules and more

Email *

Student name *

Student Grade Level

other

Student’s Phone Number

Student’s Email

Parent/Guardian Name

Parent/Guardian Phone Number

Parent/Guardian Email

Home Address

Student’s Insurance Provider

Any Allergies/Medical Needs/Special Instructions?

I give my student permission to attend the 2022 Winter Retreat with Fishersville UMC Youth. I/we understand that my student will be riding in personal vehicles with drivers who have been background screened for safety. I/we understand all reasonable safety precautions will be taken at all times and its agents during the events and activities. In the event of an emergency affecting the health or welfare of this participant, the adult chaperones have permission to administer first aid and/or transport the individual to the nearest doctor or hospital for further medical attention, as deemed necessary. The individual action in response to the emergency will be held blameless. Any medical expenses occurring will be borne by the parents or guardians of the participant. *

Yes

Required

Students will be expected to stay with our group from February 25-27. The retreat will be held at Camp Overlook in Keezletown, VA. Please list any schedule changes that need to be accommodated for your student here:

We are in need of some volunteers to make this experience possible for our youth. If you can help with any of the following, please check.

I can chaperone for the weekend

I can provide a meal

I can attend as a mentor on Saturday evening

I can bring an extra air mattress

My student is planning on participating at Valley Jump on Friday and Snow Tubing on Saturday

Yes, and student needs a ticket

No, student will have some down time at that time.

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Registration Fees can be sent via check (Made out to FUMC with the For line: Youth Retreat), cash or Venmo to @Lauren-Sandercock-1

Retreat only ($30)

Retreat add Valley Jump and Snow Tubing ticket ($70)

I am bringing a friend (-$10 from your registration)

There are multiple students traveling with my family. (-$15 from each student's registration)

Sign via typing your name below: *

A copy of your responses will be emailed to the address you provided.

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