What: a Retreat with Other Churches from All Over the Southeast

Restore 2010

What: A retreat with other churches from all over the southeast.

Where: Myrtle Beach, the Embassy Suites at Kingston Bay (1-843-449-0006)

When: September 24-26

Who: David Skidmore (of Impact fame) will be the speaker for the weekend, and Jordan House will be the worship leader. The theme for the weekend is NALOPKT. (google it if you don’t know what it means and are curious)

Registration Information:

1. Register online at http://www.summervillechurchofchrist.com/scoc/restore_registration by August 15.

2. Fill out the Medical Release information below, cut off and put in the pink box outside the Youth Room with a $75 registration fee by September 1.

Medical Release

I have given my child permission to take part in the event, that is listed on the other side of this page, that is sponsored by S'VILLE CHURCH OF CHRIST as indicated by my signature. In the event that he or she is injured while participating, I do hereby authorize and consent to any x-ray, examination, anesthetic, medical, or surgical diagnosis rendered under general or special supervision of any licensed medical staff member. It is understood that this authorization is given in advance of any specific diagnosis or treatment being required but is given to provide authority and power to render care which the aforementioned physician, in his or her best judgment, may deem advisable. It is understood that effort shall be made to contact me, the undersigned, prior to rendering treatment to my child, but that any of the above treatment will not be withheld if I cannot be reached.

Signed:______Date:______

PERSONAL INFORMATION

Student's Full Name______

Phone______Birthday______Sex______

Address______

City, State, Zip______

Current Grade______School: ______

INCASE OF EMERGENCY NOTIFY:

Full Name______Relationship: ______

Phone: ______Address: ______

City, State, Zip: - ______

MEDICAL INFORMATION

Medical Insurance Company: ______Policy #: ______

Insured ID or Member #: ______Phone #: ______

PHYSICAL LIMITATIONS OR SPECIAL INFORMATION ______

MEDICATIONS YOU TAKE ON A REGULAR BASIS: Did you bring them with you? YES NO

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