2017 Vintage - HS Fall Retreat!

* required information


STUDENT INFO

Student's First Name*:

Student's Last Name*:

Nickname:

Gender*:

Birthdate mm/dd/yyyy*:

Age*:

School*:

Grade*:

Student Cell Phone Number*:

Student Email*:

t-shirt size*:


Address:

City:

State:

Zip:

Who do you live with?


PARENT/GUARDIAN INFO

Parent/Guardian Name:

Cell Phone:

Parent/Guardian Name:

Cell Phone:

Parent/Guardian Email*:


Medical Needs (medical/dietary/physical needs):

I will be be at Vintage the entire weekend*:
Yes No

If "No," here is when I expect to be gone (I will also fill out a Time Away card with this information upon arrival at Vintage):

**I understand that all students must have a medical release form on file (pick up in EPIC office or download on our website).
Yes No


*PHOTO/VIDEO RELEASE
For privacy and safety, we will not publish names with photographs/videos.
I authorize the use/release of photographs and/or videos that include the INDIVIDUALS NAMED ABOVE for UCUMC use, in print and electronic materials (worship videos, e-mail blasts, church website, Facebook, etc.).

Photo/Video Release Given
Photo/Video Release Denied


*RELEASE: Submitting this on-line form will be the equivalent of signing a paper registration form.
Yes, I agree

Name of Adult filling out this form*:

Date Electronically Signed mm/dd/yyyy*:

I plan to pay via*: Online Check
Due upon registration.



Please enter the text from the image in the box