Clone of 2025 Camp Utmost Winter Retreat

Winter Youth Retreat Registration

Join us January 30 - February 1 for our Winter Youth Retreat! The retreat begins 5:30 PM Friday and ends 1:30 PM Sunday. The retreat is open to grades 7-12. 6th graders are welcome if they attend with a youth group. Counselors needed, please apply online! Early Bird pricing available through the end of 2025. Regular pricing begins January 1.
Camper's Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Grade Currently In *
Current Age:*
Gender:*

MaleFemale
Phone Number*
E-mail Address (for confirmation and information):*
example@example.com
Home Church (if applicable):
Cabin Roommate Requests: Please list full names of up to 2 friends to room with. Friends must register online within a week.
Emergency and Medical Information
1st Emergency Contact Name*

First NameLast Name
1st Emergency Contact Relationship:*
1st Emergency Contact Daytime Phone Number:*
1st Emergency Contact Evening Phone Number if different:
2nd Emergency Contact Name:*

First NameLast Name
2nd Emergency Contact Relationship:*
2nd Emergency Contact Day Phone Number:*
2nd Emergency Contact Evening Phone Number if different:
Please list other important emergency contacts, their relationship to camper, best phone numbers or other contact information that will be helpful in an emergency.
Doctor's Name or Medical Clinic:*
Doctor's Phone Number:
Does the camper have any medical allergies (including severe food allergies)?*

YesNo
List all medical allergies and the reaction that is caused.*
Does the camper have any food allergies or intolerances that the kitchen should be aware of?*

YesNo
Select food restrictions. Any restrictions selected will incur an additional fee. With Celiac Disease, we do our best to avoid cross-contamination but we have a shared kitchen and cannot make guarantees. If there are any food restrictions not listed, type them under "other". We will not be able to accommodate vegetarian diets or any overly restrictive diets not listed here. In that case, please select "will bring own food". We will be happy to provide a copy of the menu, but meals and snacks must be already prepared and ready-to-eat.*

+$10 Gluten (Celiac Disease)+$10 Gluten/Wheat (non-Celiac)+$10 Dairy Allergy or Severe Intolerance (no dairy of any type or amount)+$10 Dairy Intolerance (mild - baked goods and butter is okay but no cheese or ice cream)Peanuts/Tree NutsWill bring own foodOther
Does the camper have any chronic illnesses or physical limitations that may affect their time at camp?*

YesNo
Please describe chronic illness and/or physical limitations.*
Will the camper be bringing any medication to camp? This includes prescription medication, vitamins, and OTC supplements. All meds must be checked in and kept with the Camp Medic.*

YesNo
Medication 1 Name*
M1 Dosage*
M1 Purpose (e.g. allergies, medical condition)*
When should M1 be given?*

With breakfastWith dinnerBefore bedAs needed (camper will check in with medic to receive meds)
Is there another medication to add?*

YesNo
Medication 2 Name*
M2 Dosage*
M2 Purpose (e.g. allergies, medical condition)*
When should M2 be given?*

With breakfastWith dinnerBefore bedAs needed (camper will check in with medic to receive meds)
Is there another medication to add?*

YesNo
Medication 3 Name*
M3 Dosage*
M3 Purpose (e.g. allergies, medical condition)*
When should M3 be given?*

With breakfastWith dinnerBefore bedAs needed (camper will check in with medic to receive meds)
Is there another medication to add?*

YesNo
Please list medication name, dosage, purpose, and time of day for all additional medication.*
Date of last tetanus shot:*
Is camper covered by medical insurance?*

YesNo
Name of Insurance Company:*
Policy Number:*
Confirmation & Payment
Electronic Signature: By entering my name below, I accept the above conditions and releases. (You must be 18 years old or over to sign below.)*

First NameLast Name
Relationship to registered camper:*
Current Date:*

MonthDayYear
For Security, type the message seen below:*
Discount Code
Discount Amt.
Calculation
Payment Amount

prevnext( X )
USDRegistration Fee + Dietary Restriction Fee

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

Winter Youth Retreat Registration

Emergency and Medical Information

Confirmation & Payment