2025 PK RETREAT REGISTRATION

SNEMN PK/MK Retreat Student

Permission & Release
PK/MK PERSONAL INFORMATION
Student's Name*
Age*
Date of Birth*

MonthDayYear
Date
Current School Grade*
Gender*

MaleFemale
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Crewneck Size (sweater)*
Let us know your top 3 activities you would like to do:*

Horseback RidingKayakingFishingWalking TrailsArcheryCanvas PaintingArts & CraftsOutdoor Sports
Parent's Name*
Parent's Cell Phone*
Church Name/Location:*
Roommate Request 1*
Roommate Request 2
Roommate Request 3
Please select your AG credential level below*
PK/MK MEDICAL INFORMATION
List any/all prescription medications that will be brought to PK/MK Retreat*
Note: Any prescription medications brought to PK/MK Retreat must be in their original container with student's name listed. All medications (prescription and over the counter) will be held by one of the leaders at all times. The PK/MK will be responsible for asking the leader for his/her medication.
List any/all present medical conditions*
List any/all allergies (including medication allergies)*
List any restrictions*
I herby give permission to event event nurse to administer any of the following over the counter medications to my child as needed, in the dosage appropriate based on my child's age and size:
OTC Medications:

Ibuprofen (Advil, Motrin)Acetaminophen (Tylenol)Pepto-BismolAnti-Acid (Tums, Rolaids, etc)Imodium ADCough DropsBenadrylBasic Wound Care (cleansing with soap & water, antiseptic, apply antibiotic ointment, bandage)
DIETARY INFORMATION
List all dietary conditions, restrictions and/or allergies*
*We will do our best to accommodate dietary conditions however, we encourage you to send your child with appropriate food as needed.
SPECIAL NEEDS
Does your child have any medical, developmental, learning, or sensory needs that our team should be aware of in order to best support them during the retreat?*

YESNO
If yes, please explain below
INSURANCE INFORMATION & EMERGENCY CONTACT
Physician's Name*
Physician's Phone Number*
Please enter a valid phone number.
Insurance Phone Number*
Please enter a valid phone number.
Insurance Provider*
Carrier's Name*
Group or Policy #*
*PLEASE UPLOAD A COPY OF INSURANCE IDENTIFICATION CARD

If you do not have insurance coverage; please list above as "none".
Upload a photo of the insurance card info. Feel free to use your cellphone.

Cancelof
Emergency Contact Name*
Emergency Contact Phone Number*
Relationship to Child*
Southern New England Ministry Network

Authorization Release/Disciplinary Clause

I understand that participation in events activities with the Southern New England Ministry Network events brings with it a certain amount of risk. I acknowledge and accept the risks of physical injury associated with participation in the activities. Should there be any activity for which I wish for my child to abstain from, I will notify the Southern New England Ministry Network events in writing at the time of registration. In consideration of the risks involved. I understand that the Southern New England Ministry Network events and Timothy Hill Ranch at Norwich Lake have taken the necessary precautions to ensure the safety and well being of my child. I hereby release and waive any and all claims against the Southern New England Ministry Network events, Timothy Hill Ranch at Norwich Lake, and its staffs arising from his/her participationin the Southern New England Ministry Network events. I also release and waive all personal financial responsibility for any injury or loss sustained during the activities and hold both the Southern New England Ministry Network (and its representatives), and Timothy Hill Ranch at Norwich Lake harmless for such injury or loss arising directly or indirectly from said activities.

The health history included in this application is correct as far as know and the person herein described has permission to engage in all prescribed activities, except as noted by the physician and me. IN CASE OF EMERGENCY, I hereby give permission to the physician to secure proper treatment, including hospitalization, anesthesia, surgery. or injections of medication for my child. I hereby give my consent, in the event that all reasonable attempts to contact me have been unsuccessful. for the administration of any treatment deemed necessary by the appropriate licensed physician, nurse, dentist or emergency personnel. I also give permission for the events Nurse to administer over the counter medication to my child as deemed necessary according to dosing guidelines and attend to any other necessary healthcare means.

I also hereby understand that if my child refuses to adhere to the events policies listed below, I may be called to bring him/her home immediately. I also hereby give permission to the events team leader and/or other member of the events staff to inspect the contents of any or all of my child's personal belongings, and to withhold and/or dispose of any improper or illegal contents. I also hereby give permission for my child to be transported off grounds to participate in the recreation activities of the events program.

If a dispute over this agreement or any claim for damages arises, the participant (or parent/legal guardian) agrees to resolve the matter through a mutually acceptable arbitration process.

**ALL SIGNATURES ARE REQUIRED OR FORM IS NOT VALID**
Parent/Legal Guardian Signature*

Clear
Parent/Legal Guardian Name*
Date*

MonthDayYear
Date
Child's Signature*

Clear
Print Name*
Date*

MonthDayYear
Date
Southern New England Ministry Network

Photo & Video Release Form

I hereby grant the Southern New England Ministry Network permission to the rights of my child's image, likeness and sound of my voice as recorded on audio or video without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.

I agree that the Southern New England Ministry Network may use such images, video and/or audio of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web

There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

By signing this form, I acknowledge that I have completely read and fully understand the above release and agree to bound thereby. I hereby release, defend, hold harmless and indemnify the Southern New England Ministry Network from any and all claims for utilizing this material.
Child's Full Name*
Street Address/PO Box*
City*
State/Province*
Postal/ZIP Code*
Phone Number*
Email Address*
example@example.com
**ALI. SIGNATURES ARE REQUIRED OR FORM IS NOT VALID**
*Child's Signature*

Clear
If this release is obtained for someone under the age of 18, then the signature of that person 's parent or legal guardian is also required.

I verify that I am the parent/guardian of the minor named above and have the legal authority to execute the above release. I have read this release and fully understand its contents. I approve the foregoing and waive any rights in the premises.
*Parent/Legal Guardian Signature*

Clear
Date*

MonthDayYear
Date
PK/MK Retreat Rules of Conduct
1. Students are under the authority of the Network staff during their stay at Retreat.
2. Students are only permitted to leave the venue if a written request by a parent/legal guardian is presented at registration.
3. Students must stay in their rooms after “Lights Out.” Any student caught outside after this time without a proper reason will be sent home.
4. Housing will be assigned by gender at birth.
5. Students are expected to conduct themselves in an appropriate manner at all times and to attend all scheduled activities.
6. Use and possession of tobacco, drugs, alcohol or other illegal contents is strictly forbidden.
7. No profanity, disrespectful or crude conversation is to be used.
8. Respect other students belongings.
9. Do not damage or deface any venue property. If something is broken, report it immediately. Unnecessary damage will be charge to the person(s) responsible. If the guilty person(s) cannot be found, the cost of the repair will be shared by each student in the room.
10. All students must check out with their parent/guardian at the Registration table
11. I understand there will be no guys in girl's rooms and no girls in guy’s rooms at any time.
Please Note: Any prescription drugs brought to camp must be in their original bottle. No over-the-counter drugs allowed! These will be provided by the Event Nurse.

Students should understand that violations of these rules may result in disciplinary action, the contact of their parent/legal guardian with the possibility of being sent home and forfeiting their registration fee.

I, the student participating in PK/MK Retreat, agree to keep all rules as announced by the leadership and listed above in this document.
Student Signature*

Clear
Please Print Name*
Date*

MonthDayYear
Date
LIABILITY WAIVER AND RELEASE
I, the undersigned, am the parent/guardian of "my child" (“my child”),
who will participate in the SNEMN Ministers Kids Retreat.

I acknowledge and understand that participation in recreational, travel, and camp activities carries inherent risks of injury. SNEMN staff, volunteers, and leaders will take reasonable precautions to ensure safety, but cannot eliminate all risks.
By signing below, I:
1. Release and hold harmless the Southern New England Ministry Network, its employees, volunteers, agents, and representatives from any liability for injury, illness, accident, or property damage.
2. Assume all risks associated with my child’s involvement.
3. Agree to indemnify and defend SNEMN against any claims arising out of my child’s participation.

This release does not waive liability for gross negligence or willful misconduct.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Printed Name*

First NameLast Name
EMERGENCY MEDICAL CONSENT
In the event of illness or injury to my child, "my child" I hereby give permission to the adult leaders of the SNEMN Ministers Kids Retreat to secure and authorize such emergency medical treatment as my child may require, including hospitalization, anesthesia, surgery, or injections of medication.

I understand that every effort will be made to contact me or the emergency contact provided before such action is taken.
Child's Full Name: *
Parent/Guardian Name:*
Parent/Guardian Phone #:*
Parent/Guardian Signature:*

Clear
Date

MonthDayYear
Date
PAYMENT SECTION

Registration Payment*

1st PK/MKOnly Select this if you are signing up 1 PK/MK or if this is the first PK/MK you are registering.

$80.00

SiblingSelect this if you've already registered 1 PK/MK.

$60.00

Enter coupon

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

Should be Empty:

SNEMN PK/MK Retreat Student

Permission & Release

PK/MK PERSONAL INFORMATION

PK/MK MEDICAL INFORMATION

DIETARY INFORMATION

SPECIAL NEEDS

INSURANCE INFORMATION & EMERGENCY CONTACT

Southern New England Ministry Network

Authorization Release/Disciplinary Clause

Southern New England Ministry Network

Photo & Video Release Form

PK/MK Retreat Rules of Conduct

LIABILITY WAIVER AND RELEASE

EMERGENCY MEDICAL CONSENT

PAYMENT SECTION

Payment Methods