citius altius fortius - THRIVE CHURCH€¦ · R e g i s t r at i o n f o r m D ECEMBER 29 - 31...
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Name___________________________________ Date of Most Recent Tetanus Booster_________ Please indicate below any: Environmental Allergies____________________ Medication Allergies_______________________ Chronic Illnesses__________________________ Send camper's medication in original bottle(s) with directions on the bottle(s). An adult staf f member will hold on and dispense all medications. If there is any other medical information that the staff would need to know about the camper, please attach a separate sheet of paper. I hereby release___________________________ into the care of the camp personnel and give my permission for him/her to be treated by Camp First Aid personnel and/or hospital or physician assigned in case of medical emergency. I will assume full responsibility for the cost of medical treatment and recognize that eve ry attempt will be made to reach me in case of emergency. Health Insurance Provider: ________________________________________ Policy #_______________________________ Parent's Signature: _______________________________________ Date__________________ Health Insurance Release Form & WHO: 6th grade - 12th grade WHEN: December 29 - 31 REGISTRATION: Begins Sunday 3 p.m. | Ends Tuesday 11 a.m. WHERE: Jericho Hills Campground Lucas, Iowa WINTER RETREAT • Bible & Notebook • Toiletries • Bedding & Towels • Old clothes for painting • Spending money for snacks OLYMPICS citius altius fortius (FASTER, HIGHER, STRONGER)
Transcript of citius altius fortius - THRIVE CHURCH€¦ · R e g i s t r at i o n f o r m D ECEMBER 29 - 31...
Name___________________________________Date of Most Recent Tetanus Booster_________Please indicate below any:Environmental Allergies____________________Medication Allergies_______________________Chronic Illnesses__________________________Send camper's medication in original bottle(s) with directions on the bottle(s). An adult staf f member will hold on and dispense all medications. If there is any other medical information that the staf f would need to know about the camper, please attach a separate sheet of paper.
I hereby release___________________________into the care of the camp personnel and give my permission for him/her to be treated by Camp First Aid personnel and/or hospital or physician assigned in case of medical emergency.
I will assume full responsibility for the cost of medical treatment and recognize that every attempt will be made to reach me in case of emergency.Health Insurance Provider:________________________________________Policy #_______________________________Parent's Signature:_______________________________________Date__________________
H e a lt h I n s u r a n c e
R e l e a s e F o r m&
W H O :6th grade - 12th grade
W H E N :December 29 - 31
R E G I S T R A T I O N :Begins Sunday 3 p.m. | Ends Tuesday 11 a.m.
W H E R E :Jericho Hills Campground Lucas, Iowa
W I N T E R R E T R E AT
• Bible & Notebook• Toiletries• Bedding & Towels• Old clothes for painting• Spending money for snacks
O L Y M P I C S
citius altius fortius ( F A S T E R , H I G H E R , S T R O N G E R )
R e g i s t r at i o n f o r m D E C E M B E R 2 9 - 3 1
Name_________________________________Male/Female_________Age________Address_______________________________City________________St______zip________Home phone__________________________Parent's name_________________________Parent's Work#________________________Cell #______________________Church________________________________Pastor________________________________
C O S T o f r e t r e at
COST: $70
After December 19th cost rises to $85.
This cost covers meals, lodging and other activities.
Please mail form and check payable to:
H E A L T H I N F O & R E L E A S E O N O T H E R S I D E M U S T B E
C O M P L E T E D & S I G N E D
R Y A N F O U S T 1 2 1 6 S 4 T H S T .
I N D I A N O L A , I A 5 0 1 2 5
For further information about Winter Retreat you can contact Ryan Foust at 515-321-9019 | [email protected]
L E A R N I N G A B O U T G O DB O W L I N G | G A M E S
S K I T S | M U S I CO L Y M P I C S B A N Q U E T
E M E R G E N C Y
C O N TA C T N U M B E R S
R Y A N F O U S T - C A M P D I R E C T O R515-321-9019
J E R I C H O H I L L S C A M P641-766-6151 citius altius fortius
REGISTER ONLINEthriveindianola.com/winter-retreat
( F A S T E R , H I G H E R , S T R O N G E R )
