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5th Grade Retreat

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5th Grade Retreat
PLEASE REGISTER BELOW | POR FAVOR REGÍSTRESE A CONTINUACIÓN
Registration ends April 19 | La fecha limite para registrarse es el 19 de abril
5th Grade Retreat Registration
The maximum number of form submissions has been reached. This form is currently not available.
- How many children would you like to register for 5th Grade Retreat? REQUIRED
  Include children needing childcare.
  Please fill out this field.
  
  Child 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Food/Medical Allergies and Special Needs or Request
  
  Child 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Food/Medical Allergies and Special Needs or Request
  
  Child 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Food/Medical Allergies and Special Needs or Request
- Photo Authorization REQUIRED
  I give permission to 5th Grade Retreat staff to take photographs of my child/children. I understand that these pictures may be displayed in the Church or used in the parish website only.
  Yes No Please fill out this field.
- Parent/Guardian
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Street Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Emergency Contact Information (Other than parent listed above)
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Relationship to Child Please enter valid data.
- Medical Information and Release
  
  Physician Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Medical Insurance Co and Policy Number Please enter valid data.
  
  I give permission to 5th Grade Retreat staff to call 911 for emergency help should my child need prompt medical attention. I give permission for my child to be transported and treated at UNC hospitals as deemed necessary by the attending physician or emergency medical technicians.
  I Agree Please select this field.
Submit