February 25-27, 2011
4-State Youth Retreat February 25-27, 2011 Registration begins Friday at 7:00 PM. Name Address City
E- Mail Church Church city Housing request Retreat Cost
Early Registration Discount -$10.00
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
Please remember to ďŹ ll out the back side!
Friday evening: 7:00 Registration 8:00 Snack when arrive 9:00 1st Session 10:30 Evening game
What to bring
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
Physicianâ€™s Name ________________________ Physicianâ€™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_________
Village Creek Bible Camp Medical Release Form