2019 H2O Retreat Registration H2O Kehukee Retreat Registration & Medical Release If you are human, leave this field blank. Date * Family Information Child's Name (First + Last) * Grade * 4th 5th Email Address * This will be used to send a copy of this registration form, and other important trip updates Mother's Name (First + Last) * Mother's Phone * Father's Name (First + Last) * Fathers's Phone * Church You Most Often Attend * MPBC OtherOther Trip Information Child's T-shirt Size Kid - Large Kid - X-Large Adult - Small Adult - Medium Adult - Large Adult - X-Large Will your child be staying for the entire retreat? If not, when will they be leaving? * Yes, staying for entire retreat No, leaving earlyNo, leaving early Payment Cash/Check App/Kiosk/Web Total cost $50. EARLY BIRD: If registration and $25 deposit received by May 5, total cost $40 If paying by credit card, use your MPBC App or pay on our website (this link will be in your confirmation email) If paying by cash/check, put in envelope in Black Box by church office door. Anything we should know about your child? Emergency Contact * Emergency Phone * Is your child bringing a friend * No YesYes Roommate Request(s) More than one request can be added, but only the first one will be guaranteed Medical Release Information Family Physician * Phone * Family Insurance Co. * Phone * Does your child have any of the following? * Asthma Sinusitis Bronchitis Kidney Trouble Heart Trouble Diabetes Seizures Stomach Upset Hay Fever OtherOther Explain/Additional InfoExplain/Additional Info **None of the above** Allergies * FoodFood Penicillin or other drug (name)Penicillin or other drug (name) Insect stings/bitesInsect stings/bites Poison Sumac, Oak or IvyPoison Sumac, Oak or Ivy OtherOther **None** If you choose one, a text box for more information will appear. Childhood Diseases * Chickenpox Measles Mumps Whooping Cough **None of the Above** Is your child up to date on immunizations for Tetanus, Polio Booster, Measles, Mumps, and others? * Yes No (please note)No (please note) Special Diet (name) Please list all medications your child is taking: Medical & Travel Release The paper Registration and Medical Release form will be created with the information on this digital form. It will need to be signed by a parent or guardian at retreat check in. The following release will be included: "My permission is granted for any Mount Pleasant Baptist Church staff member or sponsor in charge of the H2O Retreat to obtain medical attention in case of sickness or injury for (child's name). "I/We, the undersigned, do hereby release, remise and forever discharge all sponsors and Mount Pleasant Baptist Church, Colonial Heights, Virginia, from any and all claims, demands, actions, or cause of action, past, present, or future arising out of any damage or injury while participating in this event. I also agree to pick up my student or reimburse MPBC for the cost of sending my student home in the event that he/she commits any infraction of the rules, puts their fellow participants in danger, or exhibits a disruptive attitude." I understand this form will be available for review and must be signed by a parent or guardian at retreat check in. I understand my child may not be dropped off without checking in. * Yes, I understand and agree No, I need to talk to Karen or Garrett to resolve something Submit