FALL RETREAT 2018 (Oct 12-14)
Please fill out this form and click submit.
Name
Phone
Address
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Email
This address will receive a confirmation email
Parent Name
Parent Phone
Parent Email
This address will receive a confirmation email
Grade
Please select one option.
6th
7th
8th
9th
10th
11th
12th
Gender:
Please select one option.
Female
Male
Shirt Size
Please select one option.
Small
Medium
Large
X-Large
XX-Large
Allergies
Rx Medication
Note Any Scheduling Conflicts (i.e. leaving for period of time / late / etc.)
Optional
Guest of
Optional
PARENT INITIAL BELOW indicates, I as the legal guardian of student as indicated in registration, give my permission for my child to participate in San Jacinto Baptist Church, here in referred to as SJBC, Student Ministry Events in the 2018 Calendar Year. I understand the nature and risk level of activity in which this child will be a participant. I also give permission for the participant to ride on or in SJBC owned, rented, or volunteered vehicles used for all activities. I authorize any staff member or chaperone of SJBC to administer and /or procure necessary medial aid at or from any licensed medial facility or physician’s office. I also authorized the selected physician(s) and/or medical facility to provide medical facility to provide medical treatment as necessary for the above participant and release of any medical information. I further agree to be responsible for any medical expenses, and and/or property damage incurred on behalf of / or by the above participant. Additionally, I understand above participant can be removed from or released from any activities up to the discretion of SJBC leadership for any un-Christ like behavior, with transportation the responsibility of the parent(s). The undersigned further herby agree to hold harmless and indemnify SJBC, it’s directors, employees, agents for any liability sustained by SJCB as the result of the negligent, willful or intentional acts of above participant, including expensed incurred attendant thereto.
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