Family Retreat Registration

Please read the entire form carefully. Thank you!

* Indicates required field

Family Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

PLEASE LIST ALL FAMILY MEMBERS THAT WILL BE ATTENDING FAMILY RETREAT

Name of Family Member *

Gender *

Age *

Untitled *

Select One *

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Select One *

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Select One *

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Select One *

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Select One *

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Select One *

Untitled *

Name of Church you attend *

Pastor's Name *

Pastor's Phone Number *

Pastor's Address *

LIABILITY RELEASE

My family and I choose to participate in camp activities and understand we do this at our own risk. We will not hold SIMC liable for injury or loss of property.

Signature *

PHOTO RELEASE

I give my consent to use my or my child/children's photograph, likeness or image, whether in still frame, voice or video format by World Gospel Mission/American Indian Field/SIMC in publications, promotional brochures, video presentations, on the world wide web and in display formats.

Signature *

MEDICAL RELEASE

I give permission for first aid treatment to be given to me or my child/children if deemed advisable by the SIMC staff.

Signature *

Date *

Insurance Company *

Policy Number *

Allergies: Do you or your child/children have any know allergies?

Select One *

If YES, please explain *

PLEASE LIST ANY MEDICAL CONDITIONS OR RECENT ILLNESSES THAT WE NEED TO BE AWARE OF: *

Emergency Contact *

Emergency Contact Phone Number *

Submit

LIABILITY RELEASE

​PHOTO RELEASE

MEDICAL RELEASE

PHOTO RELEASE