Crossroads Retreat 2022 Student Registration

Please enter the student information for one child only.

Student Info

Name

Gender

Grade

6th 7th 8th 9th 10th 11th 12th Graduate

Student Phone

Address

Allergies

Dietary Restrictions

Current Medications

Health Insurance

Health Insurance Company

Policy Number

Name Of Insured

Parent Info

Parent Name

Parent Number

Parent Email

Emergency Contact Name

Emergency Contact Number

Student Read & Sign

Please click the following link to view the Crossroads Covenant. After you are done reading, please type your name in the box below as a digital signature.

Crossroads Covenant

Students Digital Signature

Parent Read & Sign

I _____ grant permission to the Allentown Presbyterian Church staff and youth leaders the authority to secure medical treatment for my child if necessary. I release the Allentown Presbyterian Church, its staff, officers and youth leaders from any liability for injury resulting from my child’s participation in this activity. I understand that in the event my child needs to be sent home for any reason (behavior included) I will be responsible for his/her transportation.

DO DO NOT

I _____ grant permission to APC to take and publish photographs, video, voice recordings, or any other likeness of my child/youth for use in published material (includes print, web-based (digital), and other media types) that may be presented in the public domain (outside Church services or Church-sponsored programs) for the purpose of promoting Church-sponsored programs, ministries, activities, or events.

DO DO NOT

Payment

* No refunds once forms / payments are submitted
* We cannot accept registration forms after Friday, June 3rd
* Questions? Contact JC Fowler. 908-216-6643 or jcfowler@allentownpresbyterian.org

If cost is an issue, partial scholarships may be available. If you want to inquire about a scholarship, select "Scholarship" from the drop down menu and contact JC Fowler.

If you'd like to make a donation above and beyond the registration fee to help offset the cost of Shepherds and potential scholarships, select "Gift" and enter the amount.

Early Early Bird Registration - $155 by Friday, April 29th.

Early Bird Registration - $170 by Friday, May 20th.

Final Registration - $185 by Friday, June 3rd.

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

June 10 - 12, 2022

Crossroads Youth Ministry
Retreat 2022

WHEN: June 10-12, 2022

WHERE: Mont Lawn Camp, 5190 Wickes Rd, Bushkill, PA 18324

WHO: Middle school & high school students (6th–12th grade)
*2020 & 2021 high school graduates are also invited

DEPART: Friday, June 10th at 4:00 pm
*Middle school - parking lot across from Allentown Presbyterian Church
*High school and young adults - Crossroads Parking Lot
*Band - Crossroads Parking Lot at 3:00 pm.

PICKUP: Sunday, June 12th at 12:15 pm
Parents, join us for the close of the retreat at the 11:00 am APC service!
*Middle school - lower lot of Newell Elementary School
*High school and young adults - Crossroads Parking Lot

COST: (No Refunds)
Early Early Bird Registration - $155 by Friday, April 29th
Early Bird Registration - $170 by Friday, May 20th
Final Registration - $185 by Friday, June 3rd

Questions?
Contact JC Fowler: 908-216-6643 or jcfowler@allentownpresbyterian.org

Crossroads Retreat 2022 Student Registration

Description

Please Fix the Following