Fall Retreat Registration

Student's Name *
Student's Name
Gender *
Coming with a friend?
Climbing Wall $5 *
Do NOT include the additional $5 in your registration cost - bring cash with you on the retreat.
Horse Back Riding $20 *
Do NOT include the additional $20 in your registration cost - bring cash with you on the retreat.
The same release as disclosed above.
Three Springs Required Information
Participant's Name *
Participant's Name
Participant's Address *
Participant's Address
Date of Birth *
Date of Birth
Guardian's Name *
Guardian's Name
Guradian's Address
Guradian's Address
(if different from participant's address)
Guardian's Phone *
Guardian's Phone
List the number to call in case of an emergency.
Emergency Contact *
Emergency Contact
In case Parent/Guardian cannot be reached
Emergency Contact's Phone *
Emergency Contact's Phone
Release as detailed above
Medical Information
Medical History *
Please check all that apply
Anything not listed above that you feel would be important for staff to know.
Allergies *
Anything not on the list above
Include a brief description