Sponsored by the Jacksonville Church of Christ

Sponsored by the Jacksonville Church of Christ

Come join us in Jacksonville Fl.October 27th-October 29thfor a weekend full of fellowship, games, classes, and more.

This retreat is for current 9th-12th Graders

The Cost is $25 per person before October 20th ($30 pp for late registration)

Lodging will be provided by host families from the Jacksonville Church

Registration:

• Registration forms available from the Teen Facilitators or at
• Print and complete registration form
• Form must be notarized
• Mail completed form to:

Jacksonville Church of Christ

Teen Ministry

6118 Bowden Road

Jacksonville Fl 32216

• The deadline to register is Friday October 20th 2017 (This is important for housing and T-Shirts. If you register after this date you will not be guaranteed either)

Once your registration is received, you will receive an email confirmation with your host family name and itinerary for the weekend.

If you have any questions please contact Chip Fowler at(904)-545-4446(), Stephanie Sorens at(757)-633-4676 (), or the Jacksonville Church main line at 904-998-0060.

Teen’s Name:______Male ___ Female___

Grade:______Age:______Shirt Size ______(small/medium/ large/extra-large/2x)

Home Church:______

Teen Phone/Text: ______

Address: ______

City State Zip

Any special medical conditions or other needs: ______

Parent/GuardianName:______

Parent/Guardian Phone:______

Parent/Guardian Email:______

Parent Address (if different): ______

City State Zip

Important Note: Waiver on Page 3 must be completed and notarized

Does your Teen need housingfor the Teen Retreat? YES / NO (Circle one)

If you said YES to your teen needing housing–Does your Teen have a housing request? Specifically, is there a specific family he/she would like to stay with, or are there specific friends who would like to be housed together? YES / NO (Circle one)

If YES please indicate who your teen would like to be housed with: ______

(While not guaranteed, we will try our best to fulfill each request)

Wavier on Page 3 below

Waiver Form

(Must be completed out by parent or guardian of a child under 18)

To Whom It May Concern:

I, ______, do hereby give permission for

my son/daughter ______, to attend and participate in all activities for the 2017 Fall Teen Retreat, sponsored by the Jacksonville Church of Christ, to be held in Jacksonville Fl.

In consideration of my son/daughter being allowed to participate in the retreat, I agree to release and hold harmless The Jacksonville Church of Christ, its employees, and contractors, retreat employees and volunteers, and all individuals associated with the program, from any and all liability (direct or indirect), for any injury or harm of any kind to my child as a result of my child participating in retreat activities or which might be incurred while my child is in transit to or from the specific activities. I, ______, also give my permission to the medical caretaker or retreat director, to seek any necessary medical attention for my son/daughter, ______, during the time frame of October 27th-October 29th, at the 2017 Fall Teen Retreat held in Jacksonville, Fl. This notification will also include the right to sign for, but not limited to, an emergency service transport, hospitalization, emergency services or surgery. I further agree to be responsible for the cost of such treatment including but not limited to costs associated with transportation to the treatment facility.

______

Parent or Guardian Signature Date

Notary only to complete after this point

State of______, County of, ______

Sworn before me this day ___, day of ______, 2017, by ______

Who is personally known to me /produced ______from identification.

______

Notary Signature and Date Notary Seal