9th Spiritist Youth Retreat - 2023
Location:   Kenwood Kenmont Camp
                   65 Kenmont Rd
                   Kent, CT 06785

Dates:        Saturday, May 27 (9:00AM Arrival)
                   Sunday, May 28 (All Day)
                   Monday, May 29 (1:00PM Departure)

Age:           13 and Up

Fee*:           $300 (includes 2 nights, 2 1/2 days, 7 meals, activities, 3 t-shirts, 1 drawstring bag)

*Payment must be made directly to your youth group coordinator by May 1st.  Only cancellation prior to May 10th will get an 80% refund.

Instructions:    Step 1. Fill out and submit this form
                          Step 2. Your Youth Group coordinator will confirm your registration* 
                          Step 3. You will receive a link to the retreat's WhatsApp group prior to event

Important Note:  The registration will be effective only after the participant provides all requested information, and read and sign the participant agreement form.                             

Additional questions:  info@akscdanbury.org

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Email *
Participant Spiritist Center's NAME AND STATE *
Your Youth Group Coordinator's Name *
Participant's FULL NAME? *
Participant’s DATE OF BIRTH: *
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/
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/
YYYY
Participant’s CELL PHONE NUMBER *
Participant's ADDRESS (Street, City, ST, Zip Code) *
Participant's Parents/Guardians FULL NAME
(if 18+, please write "Self")
 *
Participant's Parents/Guardians CELL PHONE NUMBER
(if 18+, please repeat your cell phone number)
 *
Participant's Parents/Guardians ADDRESS (if different than Participant's address)
Participant's T-SHIRT Size *
Participant's FOOD PREFERENCES/RESTRICTIONS
Primary Care Provider NAME *
Primary Care Provider PHONE NUMBER *
Health Insurance Name/Number or Medicaid/Number *
Dental Insurance Provider NAME AND PHONE (If available)
Do you take any medication? *
Please list medication if answered "Yes" to above question.
Does the participant's parents/guardians and participants 18+ authorize the Youth Retreat Coordinators to make medical decisions in case of an emergency? *
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