Mount Vernon Nazarene University: Life Changing

Clergy Kid's Retreat Registration Form


This form is currently down due to updates made by our e-commerce partner. We expect it to be available soon.




Please complete the following fields.

Name:
First Name:
Last Name:
Gender:
Birthdate:
Grade:
Street Address:
City:
State:
Zip:
Home phone:
Student cell phone:
Parent cell phone:
Parent cell phone 2:
Student email:
Parent email:
Parent email 2:
Church name:
School:
Suite-mate Request:
(2 names max.)
Parent/Guardian's Names:
Any comments or questions?:
Payment Info
Registration & $25 deposit deadline is Jan. 7. Balance & Medical Release due Feb. 4.
Amount paying with registration:
Pay by:
Credit Card Online
Check Online
Check by Mail


For more information, please contact:
Trinia Huddleston
Mount Vernon Nazarene University
800 Martinsburg Road, Mount Vernon, OH 43050

 
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