Clergy Kid's Retreat Registration Form

Please complete the following fields.

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 & $50 deposit deadline is Jan. 4. Balance & Medical Release due Feb. 4.
Amount paying with registration:
Pay by:	Credit Card Online Check Online Check by Mail
Security Check Please type both words separated by a space below.

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