Winter Retreat 2018 Registration

Student Information

If you are an ADULT CHAPERONE, please fill out BOTH STUDENT and PARENT section with YOUR info.

Student First Name *

Student Last Name *

Grade *

Gender *

Street Address *

Address Line 2

City *

State *

Zip Code *

Student Cell Number

Please select your shirt size. (Pick a one t-shirt size large then you, they tend to shrink)

(Beginning 3 weeks out we cannot guarantee that your student will recieve the correct size shirt or any shirt. We make every effort to ensure that all participants receive a shirt, but due to print turn around times, this is the policy) *

Friend of: (who would you like to be in a small group with)

Parent Information

First Name *

Last Name *

Phone Number

Cell Number *

Email Address *

Payment Information

Student Registration *

Full Balance ($180.00)

Deposit (50.00)

Remaining Balance (130.00)

Waiting List (Your registration will not be complete until you make a deposit).

Adult Chaperone (0.00)