Winter Retreat Online Registration

You may register in one of two ways:

a)	fill in all the information below and submit this form, in which case, you would bring with you the filled out release forms, and $60 when you arrive at Hashawa for the retreat; or
b)	print off the registration form (which includes the release forms) and send it along with $60 to the specified address. Please do not do both.

Please provide the following information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home Phone
E-mail	* For your confirmation e-mail

Date of Birth
Sex	Male Female

The name of your congregation (or the one you're coming to the retreat with):
Your youth advisor's name:
Your advisor's phone #:
Will you perform in the variety show?

Yes
No
If yes, give a brief description of your act:
Choose one of the following options:
Special needs:

You will need to bring with you:         (all these are on the same page)
     - a Covenant Agreement, signed by you;
     - a Medical Release form - signed, with information, by your parents; and
     - a Hashawa Environmental Center release form
              - signed by you (if you're 18 or older), or your parents (if you're not)

Copyright © 2002. Church of the Brethren Mid-Atlantic District Youth.
Revised: December 10, 2007