Student Information
Name *
Name
Birthday *
Birthday
Home Address *
Home Address
I agree to abide by all guidelines and policies of the Prairie Lakes NYI for Fall Retreat and also agree to conduct myself in a manner that pleases God, my family, and my church. I also understand that disobedience to the rules could result in me being sent home at my expense.
Date *
Date
Parent/Guardian Information
Name *
Name
Phone *
Phone
Alt. Phone
Alt. Phone
Emergency Contact (if parents can't be reached)
Name *
Name
Phone *
Phone
Medical Information
Date of Last Tetanus Shot *
Date of Last Tetanus Shot
Release Of All Claims
I hereby approve the application, certify its correctness and expressly wave any and all claims against the Prairie Lakes Church of the Nazarene NYI, any of its District Boards, and its representatives because of any injury or other damage that may have incurred to my child or his/her property in connection with or incident to or travel to or from the Prairie Lakes NYI Fall Retreat and related events. Permission is hereby given for images of retreat experiences that include my child(ren)'s likeness to be used in promotions of retreat activities. IN CASE OF MEDICAL EMERGENCY: I hereby understand that every effort will be made to contact parent or guardian listed. In the event I cannot be contacted, I hereby give permission to the physician selected by the staff to secure proper treatment of my child for and to any injections, hospitalization, anesthesia, or surgery for my child as named on this form.
Date *
Date