2026 Lake Champion Youth Retreat

Date: April 10th -12th

Location: Lake Champion
Glen Spey, NY

Total Cost: $225
Feb 15th - $50 Deposit is due (Non-refundable)
Mar 15th - Final Payment due

Make checks payable to Crossroads Church of Shamong

Youth Information

Name

Date of Birth

Gender

Male Female

Current Grade

Parent Information

Contact Person #1

Relationship

Mother Father Legal Guardian Family/Friend

Address

Home phone #

Cell Phone #

This address will receive a confirmation email

Contact Person #2

Relationship

Mother Father Legal Guardian OptionFamily/Friend

Phone

Church Information

Please complete if you are not apart of Crossroads

Church Name

Youth Leader Name

Phone

Medical Information

Health Insurance Policy and Group # (Please provide a copy of the front and back of your insurance card)

Is your child presently taking any medications or carrying emergency medicine?

Yes No

If yes, please list

I understand that if there is any medications that will be accompanying your child: a. Your child must be able to administer their own medication. (Unless otherwise noted) b. All medications must be in the original prescription labeled container.

I accept No medication will be accompanying my child

Does your child have any physical handicap or illness taht would prevent them from participating in normal rigorous activity?

Yes No

If yes, please list

Do you have any special dietary requests/needs?

Yes No

If yes, please describe

Does your child have any food, medicine or other type of allergies?

No known allergies Yes, my child has allergies and carries an EpiPen Yes,, my child has allergies but does not need an EpiPen

If yes, please list

Consent and Certification

My child will be expected to observe all rules regulations. Luggage, lodging rooms, and personal belongings are subject to inspection and search at any time by leaders of the event.

I agree and understand

I give permission for my child to participate in any and all water activities

Yes, my child can participate in all water activities No my child is not allow to participate in any water activities

I give permission for all photos taken or social media posted on the church’s various media sites, (i.e., Facebook, website, Instagram, pamphlets, etc.), with no expectation of any form of payment that may include my child

Yes, I consent No, I do not consent

I hereby give my child permission to participate in 2026 Lake Champion Retreat.. I give permission to the leaders involved to render First Aid, should the need arise. In the event of an emergency, I give permission to the physician, hospital, and medical staff, selected by the adult leader in charge, to hospitalize, secure proper anesthesia, order injection and medication, or secure other medical treatment, as needed. I further agree to hold Crossroads Community Church, officers, members, leaders, and volunteers of this group harmless for any accidents that might occur during this outing. I further absolve and hold harmless the location site, drivers, and transportation vehicle(s) to and from the activity location. I further understand that I am solely responsible financially for any and all costs incurred, including but not limited to medical cost.

I accept I decline

To the best of my ability all information is true, complete and current. I agree to notify the youth leaders at Crossroads of any changes to the above information provided. Any false or misleading information will render this agreement null and void. I also understand my child will not be allow to attend 2026 Lake Champion Youth Retreat for such reason.

Signature

Date

2026 Lake Champion Youth Retreat

Description

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