Rooted Fall Undergraduate Retreat 2022 Registration Form

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Important Retreat Information:
- October 14-16, 2022 at Camp Wapsie in Coggon, IA (check in starts 4:30 pm Friday at Newman - 1:30 pm Sunday arrival back at Newman)
- Deadline to register online and pay $40 is Thursday, October 6, 2022. No refunds.
- Before you leave for the retreat you will be asked to sign a waiver
- Transportation provided by bus, no late arrivals or early dismissals

First Name *

Last Name *

E-mail address *

Cell phone number *

Local Address *

Year in School *

Freshman

Sophomore

Junior

Senior

5th Year

6th Year

Gender *

Female

Male

Major *

Date of Birth *

T-shirt size *

XXL

Form of Payment ($40) *

Cash or check (made out to Newman) to Christine

Venmo @givetoNewmanIC

Do you have any food allergies or dietary restrictions? Please explain. *

Please list prescription medications you are currently taking. *

Do you have any other allergies or special needs that we should know about to make sure you are accommodated? Please explain. *

Health Insurance Provider *

Health Insurance Plan Number *

In the event of an emergency please contact: *

Emergency contact's phone number *

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