1) Print this page
2) Fill out the Registration Form
3) Have a parent sign the Medical Release Form
4) Make out a check payable to Northern Yearly Meeting
5) Send registration to Mary Klos (W404 Cty K, Brillion, WI 54110, or 920-883-8611 or calumetdreams@yahoo.com)
What does it cost?
$20 per family for food and expenses - Scholarships are available - just ask!
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Registration Form for Fall NYM 7th and 8th Grade Retreat
November 11-13, 2011 at Madison Friends Meeting House, Madison, WI
By attending this retreat, you are making the decision to participate
cheerfully and cooperatively in all of the planned activities so everyone
can have a fun weekend together. Disruptive behavior which hurts the community
is not acceptable. If disruptive behavior continues after two warnings,
parents will be called and the disruptive teen(s) will be asked to leave early
to restore harmony for the group. Signing this registration form tells us that
you have read this message and you understand these expectations.
TEEN's NAME(Signature):______________________________________________________
TEEN's NAME(Print):______________________________________________________
ADDRESS:___________________________________________________
PHONE:__________________ E-MAIL____________________________
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MEDICAL RELEASE FORM
I give permission for my child(ren) named above to participate in the 7th and 8th Grade Friends Weekend at
Madison, WI on November 11-13, 2011 and to participate in all planned program activities. I hereby release
Northern Yearly Meeting and Madison Friends Monthly Meeting, and their volunteers, from liability for any injury
or illness that my child may experience during the weekend. In the event of an emergency, I hereby authorize
the Weekend adult organizers to consent to any medical or surgical care advised by licensed health care
providers. I hereby release Northern Yearly Meeting and Madison Friends Monthly Meeting from any liability, legal
or financial, for emergency care provided to my child. I expect to be informed as soon as possible.
Parent’s Signature: ___________________________________________
Any special medical conditions or diet restrictions we should be aware of?
_________________________________________________________
In case of emergency, you can reach me at this number during the weekend of November 11-13, 2011:
_________________________________________________________