Family Application

Family Application
Name*
First NameLast Name
Email*
example@example.com
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number*
Area CodePhone Number
Your Information
Which Family Retreat would you like to attend*
Maranatha Week 1 (June 10-14, 2019)Maranatha Week 2 (June 17-21, 2019)Urban (Aug 11-15)
T-shirt Size*
Church Name
Primary Language*
List any other languages you use for communication other than English.*
Is your family bringing a Personal Care Attendant (PCA)?
YesNo
Name of your PCA
First NameLast Name
Medical Information
Insurance Policy Carrier*
Insurance Policy Number*
Physician Information*
First NameLast Name
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Area CodePhone Number
Additional Notes
What other Family Retreats have you attended?
How did you hear about Joni and Friends?*
If other, please tell us how
Your Information
Gender*
MaleFemale
Date of Birth*
MonthDayYear
Date
Marital Status*
Do you have a disability?*
YesNo
What disability do you have?
Do you have any Medical Conditions.*
YesNo
List any medical conditions you have.
Do you require any special accommodations?*
YesNo
Please describe these accommodations.
Do you require medical equipment?*
YesNo
Please describe
Have you been treated for mental health concerns?
YesNo
What is important for us to know about your disability or medical conditions?
List any medications you take. What happens if you miss your medications?
Do you have any allergies (Seasonal, Medication, Food, etc.)*
YesNo
Please list these allergies and what happens when you have a reaction.
Emergengy Contact Information
Emergency Contact 1
Name*
First NameLast Name
Relationship*
Email*
example@example.com
Phone Number*
Area CodePhone Number
Emergency Contact 2
Name*
First NameLast Name
Relationship*
Email*
example@example.com
Phone Number*
Area CodePhone Number
Family Consents
Please review the Family Participation Consent for Joni and Friends Family Retreats.
I agree to the Family Participation Consent*
YesNo
Please review Joni and Friends Photo, Video, and Audio Release.
I agree to the Joni and Friends Photo, Video, and Audio Release.*
YesNo
Information Sharing - I give my consent to have my contact information shared with other attendees in the Family Retreat Directory. (*Joni and Friends does not share information with anyone outside of the ministry.)
YesNo
Financial Agreement - If I am approved to the Outreach, I agree to the Outreach Cost and the fundraising deadlines given and understand that all funds are due one month before the Outreach. I also understand that all funds given to Joni and Friends toward my Outreach costs are non-refundable.
YesNo
How many additional family members?

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Family Application

Family Consents

Additional Family Members