Students' Fall Retreat 2026 Registration Form

STUDENT INFORMATION

Student Name

Birthdate

Grade

Gender

Male Female

T-shirt Size (Adult)

Student Email

Student Phone

Address

Invited by

PARENT / GUARDIAN INFORMATION

Parent / Guardian Name

Relationship to Student

Phone

This address will receive a confirmation email

MEDICAL & DIETARY INFORMATION

REQUIRED FIELDS - ENTER NONE IF NOT APPLICABLE

Medical Conditions / Allergies

Dietary Restrictions

Other Emergency Contact & Phone

APPOINTMENT OF MEDICAL AUTHORITY
I hereby give permission to the medical personnel selected by the Student Pastor or his designees to order x-rays, routine tests, and treatment for the student(s) to which I am registering for in the event I cannot be reached. I hereby give permission to the physician selected by the Student Pastor or his designees to hospitalize, secure proper treatment for, and to order injection, anesthesia, and/or surgery for my child(ren) as named above. I will not hold the Student Pastor, his designees, or Hillcrest Baptist Church liable for anything that may happen to my child, including death.

Consent to the Medical Authority above

Yes

Type Name for Signature

INSURANCE INFORMTION

REQUIRED FIELDS - ENTER NONE IF NO INSURANCE

Carrier

Policy Holder

Policy Number

Insurance Card Images

Upload (8MB)

PUBLICATION RELEASE

I hereby give Hillcrest Baptist Church and parties designated by them, including clients, licenses, purchasers, agents, publishers, and periodicals, the irrevocable right to use my child’s name and/or photograph for sale and reproduction in any print or electronic medium for purposes of advertising, trade, display, exhibition, competition, or editorial use pertaining to ministries, activities, or events of Hillcrest Baptist Church. This includes use on websites and all social media. I have read this release and understand and agree to its terms.

Consent to the above PUBLICATION terms

Yes No

Type Name for Signature

STATEMENT OF UNDERSTANDING & AGREEMENT OF REGISTRATION FORM

I understand that this Medical/Release Form is valid and that by signing this, my child has my express permission to participate in all activities, of any, nature, sponsored by the Church for the given school year as stated above. If I desire to limit my child’s participation in any event, I will submit my wishes in writing to the Student Pastor prior to that event. I understand that there are inherent risks involved in any ministry or athletic event and knowing that the church will always try to act responsibly, I fully release the church, its pastors, employees, and volunteer/workers/chaperones/sponsors from any and all liability for any claim, including, but not limited to injury, loss, or damage to person or property that may occur during the course of my child’s involvement. Students may sign for themselves if they are 18+.

Consent to the above REGISTRATION terms

Yes

Type Name for Signature

PAYMENT

PAYMENT OPTIONS

This retreat will cost $100 per student. THIS IS NONREFUNDABLE. The cost will include payment for lodging, food, and a t-shirt. Please read below for our available payment options:

1. Credit/Debit at the time of registration.

Choose the link below to pay.

2. Cash or Check PAYMENT IS DUE 1 WEEK PRIOR TO RETREAT (November 6)

Give Pastor Benji or one of our leaders the complete payment for your family's camp cost via cash or check.

PLEASE NOTE: If, for any reason, this cost is a hardship for you, please choose the Cash option and reach out to Pastor Benji. We can't express enough how we don't want finances to be a reason why your student(s) can't come to this retreat.

Payment Type

Credit/Debit Check/Cash

Click here to pay $100.00 with a Credit/Debit card before hitting SUBMIT.

Once you have completed the payment form, be sure to return to this window and click SUBMIT.

Students' Fall Retreat 2026 Registration Form

Description

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