2019 H2O Retreat Registration

H2O Kehukee Retreat Registration & Medical Release

Family Information

This will be used to send a copy of this registration form, and other important trip updates

Trip Information

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.
More than one request can be added, but only the first one will be guaranteed

Medical Release Information

If you choose one, a text box for more information will appear.

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."

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