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Teen Winter Retreat Registration
If you are human, leave this field blank.
First Name
*
Last Name
*
Address
*
(Street, City, State, Zip)
Phone
*
(xxx-xxx-xxxx)
Email
*
(To receive confirmation of registration.)
Gender
*
Male
Female
Date of Birth
*
(DD/MM/YY)
Grade
*
6th
7th
8th
9th
10th
11th
12th
Home Church
Parent/Guardian Name(s)
*
Emergency Contact Person
*
Emergency Contact Person'sPhone
*
(xxx-xxx-xxxx)
Medical / Personal Notes
Having read the CLAY Winter Retreat flyer, I agree to allow my youth to attend. I relinquish New Life Church, Abba's Haven, volunteer workers and anyone associated therein of any liability described within the brochure.
*
Accept
Pay
*
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to open a separate online payment page.
AFTER YOU HAVE COMPLETED YOUR PAYMENT, you must then click the "SUBMIT" button below on this page in order to complete your registration.
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