Please complete this form to register and give permission for your child to attend the Youth Retreat to be held at the Bethlehem Baptist Church Compassionate House on Saturday, May 21st, from 8 am to 10 pm.

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* 1. Name of Parent Completing Form

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* 2. Name of Child Attending Youth Retreat

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* 3. I give permission for the above-named child to participate in the Bethlehem Youth Retreat on Saturday, May 21st from 8 am to 10 pm.

Health Declaration
In the event of an emergency it is vital that we have contact details for your son/daughter.

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* 4. Contact information for the above-named child attending the retreat, if applicable.

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* 5. Note any known allergies/disabilities for the youth attending the retreat.

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* 6. Emergency Contact #1

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* 7. Emergency Contact #2

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* 8. I agree that the information stated above is correct and that the information may be distributed to leaders it may concern.

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* 9. Signature of Parent/Guardian

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100% of survey complete.

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