The River of Living Water Church

Summer Retreat 2012 Registration and Medical Consent

Date:
Time:

08/03/12 (Friday) 08/05/12 (Sunday)

Meet on Friday 6 p.m.
Return on Sunday 12 p.m.
Location: 5889 Alianthus Road
Phelan, CA 92371
(in San Bernardino County)
Cost:
$75 (includes lodging and meals)
Cash or check payable to River of Living Water Church
Things to bring:
Bible, sleeping bag, toiletries, change of clothes for 3 days, flashlight,
walking/tennis shoes, sleepwear, an open heart to worship God!
Banned items: playing cards, ipods, ps2, discman, etc.
Meeting Place:
2865 West 7th Street
Los Angeles, CA 90005
Contact:
Grace Kang (626) 354-7740 for questions
Name of Retreat Attendee:_____________________________________________
Date of Birth:_______________________________________________________
Grade in School:_____________________________________________________
Address:___________________________________________________________
Telephone:_________________________________________________________
Emergency Contact Telephone Number:__________________________________
Parents Name:______________________________________________________
Any Medications or Allergies:__________________________________________
I give permission to the retreat leaders to use their judgment in obtaining medical
care or treatment for the student in case of an emergency. I acknowledge that my
child voluntarily participates in these activities and release the retreat leaders and
River of Living Water Church and all its members from any liability arising from
my childs participation in this retreat. I also give permission to the retreat leaders
to provide transportation to and from the retreat site for my child.
Parents Signature:___________________________________________________
Date:______________________________________________________________