Creating Community Retreat — YOUTH REGISTRATION

Please fill out this form and click submit.

Who are you registering?

Registering my child/youth

Please select all that apply.

Option

Participant Information

Youth full legal name

Preferred name

Date of birth

Current grade

Youth email

Youth phone number

T-shirt size

Dietary needs (i.e. vegetarian, gluten-free)

Parent / Guardian Information

Parent/guardian full name

Relationship to youth

Address

Phone

This address will receive a confirmation email

I am the legal parent/guardian and have authority to give consent for this participant.

Please select all that apply.

Yes No

Emergency Contact

Emergency contact full name

Relationship to participant

Emergency contact phone number

Overnight Basics

Dietary restrictions or food allergies

Are there any immediate medical concerns we should be aware of at check-in?

Please select all that apply.

Yes No

(Full medical details will be collected in the required Medical Release & Care Form.)

Agreements & Expectations

Please read and acknowledge each item below:

Please select all that apply.

I have read and agree to the Unity Heart Agreements. I understand this is an overnight retreat and that all participants are expected to follow behavioral and substance-free expectations. I understand that participation requires completion of a Medical Release & Care Form.

Photo and video consent

Please select all that apply.

I give permission for photos/videos to be taken and used for Unity Lynnwood purposes. I do not give permission for photos/videos.

Consent Acknowledgment

Typed names serve as acknowledgment and consent.

Youth participant full name

Parent/guardian full name

Payment

Retreat fee

Pay now ($125.00) Pay later (leave amount blank) I am requesting financial assistance (leave amount blank)

Amount

Optional contribution to support youth participation

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

Please fill out this form and click submit.

Creating Community Retreat — YOUTH REGISTRATION

Description

Please Fix the Following