Youth Alive Summer Retreat Registration Step 1 of 5 20% Camper InformationName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Grade Last Completed(Required)Please choose one: Junior High (6th-8th grade) Senior High (9th-12th grade) Staff / Chaperone Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) T-Shirt Size(Required)Youth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult X LargeAdult 2X LargeAdult 3X Large Parent / Guardian InformationParent / Guardian(Required) First Last Phone(Required)Email(Required) Relationship(Required)Parent / Guardian First Last PhoneEmail RelationshipAdditional Emergency Contact InformationEmergency Contact #1 First Last PhoneEmail RelationshipEmergency Contact #2 First Last PhoneEmail Relationship Health & Medical InformationPlease note any allergies, medications, or any other applicable medical information (health history, injuries, physical or mental conditions, illness, etc.)Allergies (Food / Drug):Medication(s) / Dosage:Other Medical Information:Physician(s)(Required)Hospital Name(Required)Date of Last Physical Exam:(Required) MM slash DD slash YYYY Date of Last Tetanus Shot:(Required) MM slash DD slash YYYY General health for the past two years:(Required) Excellent Fair Poor Special Notes or Instructions: Summer Retreat RulesRules Acknowledgment(Required)To ensure the safety and compliance of all attendees, all bags and personal items will be inspected by staff at check-in. All medications must be stored with staff and will be administered by staff/with staff present. No cell phones, personal music devices, electronic games, computers, tablets, walkie-talkies, or two-way radios. (Staff has means of communication in case of an emergency.). Any of these items will remain in the possession of the staff until check-out. No smoking, vaping, drugs, alcohol, sexual activity, cursing or vulgar language, destruction of property, fireworks, or weapons of any kind. No guys in girls' rooms, girls in guys' rooms, leaving rooms at night, skipping services, pranking or hazing, or getting into other people's belongings. No outside snacks or drinks, except water. (Living Waters Bible Camp does not allow food or beverages in the cabins due to pests.) Meals are provided by Living Waters Bible Camp, and there are snacks for purchase at the camp store. Dress code: We're not measuring shorts and tank top straps, but if clothes are too revealing, you will be asked to change. No two-piece swimsuits. If you have clothing questions, ask before you check in. Participation: Your attendance and participation are mandatory at all scheduled events and activities. The more involved you are, the more you'll get out of the retreat. Violations of these rules, or additional instructions given during the course of the retreat, will result in verbal warning issued by staff. Continued incidents may result in disciplinary action, up to and including dismissal from the retreat. I have read and understand these rulesRelease from Liability & Emergency Care:Liability & Emergency Care Acknowledgment(Required)I, the undersigned, give my full permission for my child to attend the 2025 Youth Alive Summer Retreat. I hereby waive all claims and hold harmless Word of Life Ministries, Inc., aka Living Word Christian Church, and any of its employees, staff, members, and/or volunteers of any liability incurred at or as a result of attending this event. If emergency or required medical care is needed, I hereby consent to such medical care as deemed necessary by medical care providers and authorized staff. I have read and understand this information.Parent/Guardian Name(Required) First Last Parent/Guardian Consent(Required) I have read, understand, and agree to the rules, release from liability, and emergency care statements above.Today's Date(Required) MM slash DD slash YYYY Payment:Online Registration Payment (Camper) Quantity(Required) Price: $195.00 Quantity Pay Online NowOnline Registration Payment (STAFF) Quantity(Required) Price: $175.00 Quantity Total Payment MethodPayPal CheckoutCredit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name CAPTCHA
