Youth Name Age M/Fspecial Needs Dietary Needs

Hartman Center Youth Retreat: Group Registration

Church Name:

Address:

Pastor/ Advisor:

Email:Phone:

YOUTH NAME AGE M/FSPECIAL NEEDS DIETARY NEEDS

ADULT CHAPERONES

NAME M/F E-MAIL SPECIAL NEEDS Dietary Needs

If you haven’t yet registered online, please do so at hcyouthretreat.eventbrite.com. There you will have the option to pay with a credit card or a check. If you choose credit card, you may mail this form or email the form to . If you choose to pay with a check, please complete this form and mail both to the following address:

Penn Central Conference 900 South Arlington Rd. Room 227A Harrisburg, PA 17109

Make checks payable to “Penn Central Conference”

Once your registration is received additional information, permission and medical forms will be emailed, please bring these along to the retreat.

What you should bring:

Sleeping bag or bedding, pillow

Towel, washcloth, personal items (toothpaste, shampoo, soap, etc)

Warm casual clothes – we hope to be outside: coat, hat & gloves

2 pairs of shoes/ boots – they might get wet and muddy

Flashlight

Bible, notebook or tablet, pen

Personal prescription or OTC medicines with instructions (see medical form) these will be given to and administered by the nurse

Snacks for sharing with the group

Also: NO FOOD OR DRINKS are permitted in our cabins DO NOT bring any illegal substances, fireworks or weapons. Do not bring personal electronics: games, tablets, pods, etc. Cell phones are best left at home, use of phones will be at the discretion of the event leaders who may take possession of any phone being used inappropriately. Registered Service animals only are permitted.

By signing below, I give permission for my child (named above) to attend the Penn Central Conference retreat at Hartman Center and to participate in all activities except as noted in the medical form. I do hereby release, forever discharge and agree to hold harmless The Penn Central Conference (UCC) its pastors, directors, employees, and volunteers from any and all liability, claims or demands for accidental 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 Participant while involved in the retreat. While there is no plan for offsite travel, I also hereby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating this retreat. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

Signature of parent/guardian: ______Date: ______

I give permission for my child to be photographed and recorded, alone or in groups and agree to have those images used for promotional purposes including print and social media sites.

Signature of parent/guardian: ______Date: ______