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February 25-27, 2011

Registration

Form

4-State Youth Retreat February 25-27, 2011 Registration begins Friday at 7:00 PM. Name Address City

ST

Phone# (

ZIP

)

-

E- Mail Church Church city Housing request Retreat Cost

$85.00

Early Registration Discount -$10.00

www.villagecreek.net

4-State Youth Retreat

Special Dietary Needs

Form must be sent on or before Feb. 15 to receive early discount.

Less Deposit $25.00 Payment Due ______

Please make check payable to VCBC, OR: to my credit card

Charge $ [

] Visa [

Exp. Date Acct. #

] MC [ ] Discover [ ] Am. Exp. / -

-

-

Signature Optional activities: Cross Country Skiing Skating Paintball Game $10 Sledding Trail Ride $12

Gym/Game Room

Please remember to ďŹ ll out the back side!


Tentative

Schedule

Friday evening: 7:00 Registration 8:00 Snack when arrive 9:00 1st Session 10:30 Evening game

Date

What to bring

Signature

Bible, notebook, pen, personal grooming articles, bedding, towel and washcloths, hard soled shoes for trail riding, tennis shoes for the gym, and long sleeves for paintball.

Parents! Please read, sign and date the following: Our insurance coverage is a primary carrier. Our policy will provide you with complete coverage within its limits, subject to policy provisions. IN CASE OF MEDICAL EMERGENCY, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for and to order injection anesthesia or surgery for my child, as named above.

1588 Drake Rd Lansing IA 52151

Physician’s Name ________________________ Physician’s Phone # ______________________ Health Insurance Co. & Address ____________ ______________________________________ Policy # _______________________________ Health Problems / Special Needs ___________ ______________________________________ Drug Allergies __________________________ Regular Medication ______________________ Activity Restrictions _____________________

Saturday: 8:00 Walk-thru Breakfast 9:00 Session 10:30 Break-out Groups 11:00 Morning Activities 12:30 Lunch 1:30 Afternoon Activities 3:00 Canteen/camp store 5:30 Supper 7:00 Session 8:30 Evening Activity

Emergency Contact ______________________ Emergency Phone # ______________________ 2nd Emerg. Contact _______________________ 2nd Emerg. Phone # ______________________

Sunday: 8:30 Breakfast 9:00 Closing Session 11:00 Brunch

Name_________________________________ Birth date ____________ M/ F Age________ Parents/Guardian ________________________ Daytime Phone # ________________________ Address________________________________ City_____________ State_____ Zip_________

vcbc@villagecreek.net

Village Creek Bible Camp Medical Release Form

Winter Four State Youth  

Youth from all around Iowa, Wisconsin, Minnesota, and Illinois come together to enjoy winter in Gods beautiful creation.

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