REGISTRATION FORMSTUDENT NAME__________________________________________________________________________

PARENT/GUARDIAN NAME(S) __________________________________________________________________

PARENT/GUARDIAN CELL PHONES ____________________________/__________________________________

OTHER PEOPLE TO NOTIFY IN CASE OF EMERGENCY.

1. ___________________________________PHONE__________________________________________

2. ___________________________________PHONE__________________________________________2. ___________________________________PHONE__________________________________________

STUDENT ADDRESS________________________________________________________________________

CITY ________________________ STATE _______ ZIP ___________ HOME PHONE _______________________

CELL PHONE _____________________________ AGE ____GRADE____________________________________

E-MAIL _______________________________________________________________________________

MEDICAL TREATMENT INFORMATIONINS. CO. __________________________________________GROUP #______________________________

POLICY/I.D. #___________________________________________________________________________POLICY/I.D. #___________________________________________________________________________

COMMENTS OR RELEVANT MEDICAL

INFO:_______________________________________________________________________________

MEDICINE BEING BROUGHT ON THIS RETREAT: _________________________________________________________

DOSAGE INSTRUCTIONS:_____________________________________________________________________

STUDENT SIGNATURE ~ I AGREE TO OBEY ALL NEXUS GUIDELINES AS STATED IN THE WINTER RETREAT BROCHURE AS WELL AS ANY VERBAL RULES THAT THE LEADERSHIP MAY ADD. I UNDERSTAND THAT IF I DO NOT ABIDE BY THESE GUIDELINES, I MAY BE SENT HOME AT MY PARENTS̓ EXPENSE.

SSTUDENT SIGNATURE ______________________________________________________________DATE_________________________

PARENT/GUARDIAN SIGNATURE ~ I HAVE READ THE WINTER RETREAT BROCHURE IN ITS ENTIRETY AND UNDERSTAND THE INFORMATION.~ I GIVE PERMISSION FOR MY CHILD TO ATTEND WINTER RETREAT 2013 AND AGREE TO PAY THE ASSOCIATED COSTS.~ I AGREE TO HOLD MY CHILD RESPONSIBLE FOR THE BEHAVIOR GUIDELINES AS STATED IN THE WINTER RETREAT BROCHURE AND WILL ARRANGE FOR THEIR TRANSPORTATION BACK HOME AT MY EXPENSE IF THEY FAIL TO DO SO.~IN THE EVENT OF AN EME~IN THE EVENT OF AN EMERGENCY, WHERE MEDICAL TREATMENT IS REQUIRED FOR MY CHILD, I GIVE PERMISSION TO THE STUDENT MINISTRIES PASTOR OR ADULT VOLUNTEER STAFF TO OBTAIN THE SERVICES OF A LICENSED PHYSICIAN. PLEASE ATTEMPT TO NOTIFY ME IMMEDIATELY CONCERNING ANY SUCH EMERGENCY.

PARENT/GUARDIAN SIGNATURE_______________________________________________________DATE __________________________

TEE SHIRT SIZE ADULT SIZES – CIRCLE WHAT YOU WANT - SMALL • MEDIUM • LARGE • X-LARGE • XX-LARGE

FILL IN THE BLANKS BELOW THAT APPLY AND INCLUDE THE PAYMENT WITH YOUR DEPOSIT:SWIMMING OR HANGING OUT IN THE LODGE ? __________________________________________ =$ 0.00SKI RENSKI RENTAL - $25.00 (STUDENT AGE 11 - $19.00) X HOW MANY DAYS? _____________________________ =$ ________SNOWBOARD RENTAL - $28.00 (STUDENT AGE 11 - $24.00) X HOW MANY DAYS? _______________________ =$ ________ LIFT TICKET - $43.00 (STUDENTS AGE 11 - $33.00) X HOW MANY DAYS? ___________________________ =$ ________BEGINNER AREA LIFT TICKET - $26.00 X HOW MANY DAYS? V__________________________________ =$ ________LEARN TO SKI/RIDE - $38.00 X HOW MANY DAYS? ________________________________________ =$ ________TUBING – $15.00 X HOW MANY DAYS? ______________________________________________ =$ ________HELMET - $HELMET - $10.00 X HOW MANY DAYS? ______________________________________________ =$ ________ TOTAL =$ ________ _______________________________________OFFICE USE ONLYDEPOSIT ($80.00) AMOUNT PD. ___________ DDATE_______CHECK_______CASH_______SCHOL.________OTHER__________BALANCE ($80.00) AMOUNT PD. ___________ DATE _______CHECK_______CASH_______SCHOL.________OTHER__________REGISTRATION COMPLETE _____