Registration

It is important you complete all of the

registration information below.

Name: ________________________________

Address: _______________________________

City: _________________________________

State: ___________ ZIP: ________________

Church Name: _________________________

Church City: ___________________________

Age: __________________

Male: _________ Female: _________

I will attend (check one)

Moon Beach Oct 8-10, 2010 ___________

Camp Pepin Oct 22-24, 2010 ___________

Scholarship Needed? ____________________

Are you attending as a chaperone? _________

Is Chaperone Male____ __ Female_________

Please return this registration form, medical release statement, and your payment to your church who will then make one check for all registrations payable to The Northwest Association of the United Church of Christ.

Medical Release Statement

I give my permission and consent for my child’s participation in the Northwest Association’s confirmation retreat at Moon Beach or YMCA Camp Pepin.

In the event I cannot be reached in an emergency, I hereby give my permission to the physician selected by the adult leader in charge, to hospitalize, secure proper anesthesia or to order medication or surgery for my child.

My child does not have any medical problems or physical disability, nor is she/he allergic to any medications except for the following:

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Signature of Parent/Guardian:

——————————————————

Date: ——————————————

Emergency Contact Information # 1:

Name: ——————————————

Phone: —————————————

Phone 2:—————————————

Emergency Contact Information # 2:

Name: ——————————————

Phone: —————————————–

Phone 2: —————————————