2025 Joplin District PK Retreat
PK Retreat is for all students of pastors AND assigned staff (paid or volunteered), in the 6th grade - College and Career.  If you have any questions you can contact Cody Swearengin at 417-840-0426 or email at rufio7070@gmail.com.
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Church Name *
Student Name *
Student Age *
Student Gender *
Student Grade Level *
Parent/Guardian Name *
Staff Position held by parent/guardian (ex: pastor, associate pastor, youth pastor, etc.) *
Home Address *
Parent/Guardian Phone Number *
Parent/Guardian Email *
Alternate Parent/Guardian Name *
Alternate Parent/Guardian Phone Number *
In case of emergency notify (if unable to reach a parent/guardian):  Need name and phone number. *
HEALTH INFORMATION
Date of last Tetanus Shot *
Check if student has had (check all that apply) *
Required
Family Physician Name: *
Physician Phone Number: *
Student Social Security Number: *
Medical Insurance Provider Name: *
Medical Insurance Policy Number: *
Please include any additional health information that Cody needs to be aware of: *
MEDICATIONS (ALL medication must be turned in to Cody upon arrival for the weekend) Please list all medication, dosages and administration information below: *

IN CASE OF MEDICAL EMERGENCY—I understand every effort will be made to contact parents or guardians of students. In the event I cannot be reached, I hereby give permission to the physician selected by the retreat director to hospitalize, secure proper treatment for, and to order: injections, anesthesia or surgery for my child, as named above.


I also give my student permission to participate in any physical activities of the retreat.

 

Please include parent/guardian name of individual filling out this form and date of "digital signature".

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