Grace Church > 2010 Delaware Valley Youth Retreat Registration

DVYR 2010 Registration Form

First Name:*	Last Name:*
Parent's Name:*
Street Address 1:*
City:*	State:*	Zip:*
Phone:*	Date of Birth:*
Email:*
Sex:* Male Female	Age Group:* High Schooler Post High School
Home Church:
Pastor's Name:
Preferred Roommate(s):
Roommate Request: We will make every effort to accomodate these requests. However, they are subject to room availability and number of requests.




Medical Information
Please list any medical problems:
Diabetes: YesNo
Allergies to medicine:
Any Severe Allergies:
Medications:
Insurance Company:
Doctor's Name:
Doctor's Phone:
Parental Release
Consent: I hereby give permission for medical care to be given to my son or daughter, named on the form above, in the event of injury or illness during 1/15-17/2010.
Transportation Release: My Son/Daughter may ride with a teenage driverMy Son/Daughter must ride with a retreat chaperone
Please Enter Full Name as Signature:*
Emergency Phone:*
Secondary Emergency Contact:*
Secondary Emergency Phone:*
Photo Directory
Directory Picture: File Size: 1000KB Maximum File Types: .jpg .jpeg .gif .bmp .png
Photo Use: Please include a photo of yourself for the photo directory with your registration. This is a fun way to remember new and old friends, but it is not required to register online.







Problems? If your registration won't submit, recheck the form to make sure you've filled in all the information, and there aren't any red error messages. Also make sure that the "Also send me a copy" button at the bottom of the page is NOT checked. Then click submit below. Not sure if your registration was successful? Check your inbox for a confirmation email. If you have a problem with PayPal's website, you do not need to resubmit your registration. Just wait for the confirmation email, which will also contain a link to pay online. Problems or questions? Email us at Retreat.Registrar.DVYR@gmail.com.
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Delaware Valley Youth Retreat 2010 Registration

Medical Information

Parental Release

Photo Directory