2025 PCC Students Retreat Registration

February 14-16 | Please fill out this form by Sunday, January 26th to Register for the 2025 Youth Retreat. Registering passed this date will not guarantee a t-shirt for the student. The cost is 50 dollars per student.

Student 1

Grade

Shirt Size

Please select all that apply.

S M L XL XXL

Student 2

Grade

Shirt Size

Please select all that apply.

S M L XL XXL

Student 3

Grade

Shirt Size

Please select all that apply.

S M L XL XXL

Parent/Guardian Name

Parent/Guardian Email

This address will receive a confirmation email

Parent/Guardian Phone Number

Student Address

Medical Information

Emergency Contact Name

Emergency Contact Phone Number

The following adult(s) may pick up the student (if child) from this event:

Please list any health issues that may affect the activities, food consumption, well-being, or medical treatment of yourself or your child, e.g. conditions like asthma, a physical handicap, allergies, heart condition, etc. Please also indicate any medications yourself or your child may be taking.

The Cost per student is $50. Please give payment for all students on this form to Zach Coblentz by Febraury 9, 2025. Cash or Check made out to Portage Community Chapel are acceptible. Thank you!

Description

February 14-16

Please fill out this form by Sunday, January 26th to Register for the 2025 Youth Retreat. Registering passed this date will not guarantee a t-shirt for the student. The cost is 50 dollars per student.

2025 PCC Students Retreat Registration

Description

Please Fix the Following