YOUTH Mountain Retreat in Brevard
9/13-9/15 | Please fill out this form and click submit.
Name of YOUTH
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Youth Grade
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Please select one option.
9th
10th
11th
12th
Select Option
9th
10th
11th
12th
Parent/Guardian Contact Email
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This address will receive a confirmation email
Parent/Guardian Phone
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YOUTH Phone
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Emergency Contact Name
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Emergency Contact Phone
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Health Information
Does your youth have any allergies?
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Does your youth have any dietary restrictions?
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Does your youth take any prescription drugs? If so please list name, dose, and frequency.
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Is there any other medical information relevant for your child? (Lingering injuries, mental health, recent surgeries, ongoing medical issues, etc.)
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Health Insurance Company
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Policy Number
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Payment
Payment
Trip Cost ($150)
Scholarships available (Email abigail@downtownchurch.me) ($0)
Trip Cost ($150)
Scholarships available (Email abigail@downtownchurch.me) ($0)
Amount
Credit/Debit Card Number
Expiration Date/CVC
Name on Card
Card Billing Address
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Description
9/13-9/15
Please fill out this form and click submit.
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