REVIVE Fall Retreat Registration 2024

REVIVE Fall Retreat Registration

October 25–27, 2024
By completing this registration form, you are giving your child permission to participate in the REVIVE Fall Youth Retreat.

Where: Association Retreat Center (ARC), Osceola, WI

Who: youth in grades 6–12

When: Friday, October 25, 4:30pm to Sunday October 27, 2:30pm

Learn more about REVIVE at: jubileeminneapolis.org/programs/revive.

You may direct any questions to Frank Schmidt (715) 937–0064
Participant Information
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Child's Gender*
Child's Grade (Fall 2024)*
Child's T-Shirt Size (Sizes are ADULT sizes)*
Medical Conditions/Allergies
Dietary Restrictions (e.g., gluten free, dairy free)
Physical Activity Restrictions or Pre-Existing Injuries
Current Medications
May we administer over-the-counter medications: (ex: aspirin, Tylenol, Advil, antibiotic ointments, etc.)*
Other important information regarding medical history, allergies, penicillin or drug reactions, use of over-the-counter-medications, etc. which we may need to know:
Would you like to register an additional child?*
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Child's Gender*
Child's Grade (Fall 2024)*
Child's T-Shirt Size (Sizes are ADULT sizes)*
Medical Conditions/Allergies
Dietary Restrictions (e.g., gluten free, dairy free)
Physical Activity Restrictions or Pre-Existing Injuries
Current Medications
May we administer over-the-counter medications: (ex: aspirin, Tylenol, Advil, antibiotic ointments, etc.)*
Other important information regarding medical history, allergies, penicillin or drug reactions, use of over-the-counter-medications, etc. which we may need to know:
Would you like to register an additional child?*
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Child's Gender*
Child's Grade (Fall 2024)*
Child's T-Shirt Size (Sizes are ADULT sizes)*
Medical Conditions/Allergies
Dietary Restrictions (e.g., gluten free, dairy free)
Physical Activity Restrictions or Pre-Existing Injuries
Current Medications
May we administer over-the-counter medications: (ex: aspirin, Tylenol, Advil, antibiotic ointments, etc.)*
Other important information regarding medical history, allergies, penicillin or drug reactions, use of over-the-counter-medications, etc. which we may need to know:
Emergency Contact
Parent/Guardian Name*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Registration Cost
Thanks to our generous financial partners, we are able to offer this retreat to each family for $40/person.

Our total cost per person for this retreat is $160. However, REVIVE will provide a scholarship for all families in need, bringing the cost per person to $40.

If you are able, you may contribute extra to help cover the cost for this camp or future camps. However, you are only required to pay $40.

Payment methods accepted:
- cash
- Cash App: $FrankSchmidt77
- Venmo: @Frank-Schmidt-7
- check: make payable to "CityJoy", note "REVIVE" in the mem
If finances are an issue, please reach out and we will be happy to discuss further. We do not want money to stop anyone from coming.

Payment is due by October 25.
How will you pay for the cost of the retreat?*
Please select payment method.
How much will your family pay?*
Medical Treatment & Liability Release
I, the undersigned parent or guardian of the child listed above, who is a minor, do hereby authorize adult workers of REVIVE to consent to any X-ray, examination, anesthetic, medical or surgical diagnosis or treatment, on the advice of any physician or surgeon licensed to practice in the state of treatment, when the need for such treatment is immediate, and when efforts to contact me are unsuccessful.

I further release, forever discharge and agree to hold harmless REVIVE, its volunteers and staff, from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the above-named child that occur during any activities.
I have read and accept the terms of the waiver of liability:*
Parent/Guardian Signature*

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REVIVE Fall Retreat Registration

Participant Information

Emergency Contact

Registration Cost

Medical Treatment & Liability Release