Winter Retreat - South Central Ohio District

Name

First Last

Registration Type

Middle School

High School

Adult

Gender

Male

Female

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shirt Size

Home Church

Emergency Contact

First Last

Emergency Contact Phone

Secondary Emergency Contact

First Last

Secondary Emergency Contact Phone

Medical Issues, Allergies, Food Sensitivities and/or Illnesses

List of Medications

Insurance (Y/N) — Name and Policy Number

Permission for Emergency Medical Treatment

With the understanding that delay in the treatment may be hazardous to my life, or I am unable to give permissionvdue to my medical condition, I hereby give my consent to administer such treatment as necessary or such surgicalvprocedure as deemed advisable. I also consent to the administration of such anesthetics as necessary.

Statement of Release

I hereby waive any and all claims against the same, or any of its Boards or Representatives, because of injuriesor other damages incurred to myself and said camper's property in connection with the South Central OhioNazarene Youth International Winter Retreat at Higher Ground Campground.

Agree

Student Participation Acknowledgement

I acknowledge and have read the South Central Ohio NYI Policies concerning Refunds and Camping which describes what is expected of me while I am participating in this District NYI event. I also understand the "Reasons for Immediate Dismissal" as the consequence to me if I choose to do any action(s) as described in the "Reasons for Immediate Dismissal" section.

I agree.

Student Signature

Parent Acknowledgement for Student Participation

I acknowledge and have read the South Central Ohio NYI Policies concerning Refunds and Camping as the parent of my child which describes what is expected of them while they are participating in this District NYI event. I also understand the "Reasons for Immediate Dismissal" as the consequence to me if they choose to do any action(s) as described in the "Reasons for Immediate Dismissal" section. I also understand that it will be my responsibility and expense to pick up my child from this event upon their dismissal.

I agree.

Parent Signature

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Winter Retreat Registration

2025 Winter Retreat