Student Leadership Retreat Registration Form

Student Leadership Retreat Registration Form

Participant Information

Date of Birth:    Student ID:    Grade/Program:

Primary Phone:    Secondary Phone:    Email:

School / Program Information

Advisor Phone:    Advisor Email:

Retreat Details

Event Name:    Dates:

Departure Date/Time:    Return Date/Time:

Participation & Transportation

Please indicate activities for which you consent to participate (check all that apply):

High ropes / challenge course
Initiative games / team challenges
Low-water activities (wading) / waterfront supervision
I do not consent to high-risk activities

Transportation arrangements (select all that apply):

School/Chartered bus
Parent/guardian drop-off & pick-up
Parent/guardian will provide transportation (must indicate driver info below)
Other (describe):

Emergency & Medical Information

Relationship:    Phone:

I authorize the retreat staff to administer non-prescription medication as indicated below: Yes    No

Financial Information & Fees

Retreat Fee: $    Payment Method: Check Card Cash

Cancellation and Refund Policy: Fees may be refunded only if written cancellation is received at least 14 days prior to departure, less any non‑refundable deposits. Medical cancellations require documentation. Participants who are removed for disciplinary reasons are not entitled to a refund.

Code of Conduct & Participant Responsibilities

Participants are expected to comply with all instructions of staff and chaperones, act respectfully toward others, and adhere to camp safety rules. Possession or use of alcohol, illegal drugs, or weapons is prohibited and will result in immediate dismissal and notification to law enforcement and parents. The sponsoring organization reserves the right to send home any participant whose behavior endangers self or others; in such cases, parents/guardians are financially responsible for transportation home.

By checking the box below, I acknowledge that I have read, understand, and agree to comply with the Code of Conduct and policies described above.

I acknowledge and agree to the Code of Conduct and participant responsibilities.

Consent, Release, and Medical Authorization

In consideration of participation in the Student Leadership Retreat, I hereby authorize and consent to the participation of the named student in all retreat activities and related transportation. I acknowledge that certain activities involve inherent risks, including but not limited to physical exertion, heights, and outdoor elements. I accept and assume responsibility for those risks, including the cost of emergency medical care.

I authorize retreat staff and designated medical personnel to administer or arrange emergency medical treatment, including hospitalization and surgery, should the need arise, and I agree to be financially responsible for such care. I further grant permission for staff to share necessary medical information with medical providers for treatment purposes.

To the fullest extent permitted by law, I hereby release, waive, and covenant not to sue the sponsoring organization, its officers, employees, volunteers, and agents from liability for any loss, damage, injury, or expense arising from participation, except for willful misconduct or gross negligence. I agree to indemnify and hold harmless the sponsoring organization for claims arising from my negligent or intentional acts.

I grant permission for photographs, audio, or video recordings of the participant taken during the retreat to be used by the sponsoring organization for promotional, educational, or archival purposes without compensation unless I indicate otherwise by initialing here:

Parent/Guardian Information (Required if participant is under 18)

Participant is 18 or older: Yes    No

Relationship to Participant:    Parent Phone:

Acknowledgment and Signature

By signing below, I certify that the information provided on this form is true and complete to the best of my knowledge. I acknowledge that I have read and understand the Consent, Release, and Medical Authorization sections above and that I have the authority to execute this form for the participant named herein. I understand that falsification of medical information or failure to disclose conditions that affect participation may result in denial of participation or removal from the retreat.

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