LGBTQ+ Youth Retreat

August 30 -Sept. 2

8th through 12th Grade

Plus Adult Sponsors*

*Each youth attending must attend with a sponsor. Multiple youth are able to have the same sponsor.

Make new friendships, share experiences, and attend to spiritual connection during the retreat.

Youth will hear from a keynote speaker, share in worship and workshops and have time to explore St.Louis.

Union Ave Christian Church, St. Louis, MO

Showers facilities will be individual (not communal) and sleeping will be in non-gendered bunk rooms

The retreat is presented by

The Walter Scott Camp & Learning Center in partnership with The Christian Church in Indiana, The Christian Church in Michigan, The Christian Church in the Upper Midwest and the Christian Church of Mid-America

Camper Information and Payment Options

Payment Options: You have the option of paying "in full" either by credit card (3.5% fee) or check.

If your church is paying a portion of the camper fee take a copy of your registration confirmation to the church and pay the church for your portion of the fee. The church is asked to make one check out to CCIW for payment of registration.

Billing information is required for all payment methods. Credit card information will not be collected unless that is your method of payment. Checks should be made out to CCIW and sent to CCIW, 401 W Jefferson St., Bloomington, Il 61701-3826.

Registration is not confirmed until payment is received.

I am Registering as:

Youth ($120.00)
Sponsor ($120.00)

Payment Options:

Credit Card (Full payment)
Check (Full payment)
Church (Full payment)

Camper Name

Perferred name

Address

Phone Number

Camper Email (if available)

Current Grade:

Date of Birth

Gender

Camper Pronouns

Home Church: NAME/LOCATION

Parent/Guardian(s) with Legal Custody

Please provide the information below, including an emergency phone number and email address for the primary parent/guardian.

Parent/Guardian 1 First & Last Name

Parent/Guardian 1 Address

Preferred Emergency Phone Number

Alternative Phone Number

Email: Updates about camp are sent via email. Please list an email that will be checked regularly.

Parent/Guardian 2 First and Last Name

Address

Preferred Phone Number

Parent/Guardian 2 Email

Other Emergency Contact

Emergency Contact Name

Preferred Emergency Phone Number

Relationship to Camper

Insurance Information

Insurance Card: The front and back of the card are required. You have the option to upload your insurance card OR fill in the information in the text box.

Uploading Insurance Card

Upload front of insurance card

Browse

Upload back of insurance card

Browse

Insurance Provider

Insurance ID

Policy Holder

Policy holder's relation to camper

Physican's Name

Physican's Phone Number

Camper Health Information

We recognize the diversity and variety in all of God’s people regarding their emotional, spiritual, physical, mental and nutritional health. The following questions are meant to help our staff be better prepared to ensure your camper’s needs are met as best as possible. It is our goal to provide the safest experience possible for all of our guests.

Please indicate any food allergies or dietary restrictions that camp staff should be aware of. If your camper experiences any food-related behavioral concerns that you think would be helpful for our staff to know, please let us know here as well. Enter “NA” if not applicable.

Diet & Nutrition

Please let us know of any social or mental health concerns that would be helpful for camp staff to know. Enter “NA” if not applicable.

Social & Mental Concerns

Please let us know of any medical concerns that would be helpful for camp staff to know. Enter “NA” if not applicable.

Medical Concerns

Please let us know of any prescriptions or medications, including over the counter, that your camper takes. All prescriptions and medications must be in original containers, including directions, dosage, and other necessary information. Prescriptions and medications must be handed over to camp staff during check-in and will be administered by an approved camp staff according to indicated prescriptions or instructions. Enter “NA” if not applicable.

Medications

Please let us know of anything that would be helpful for our staff to know. Enter “NA” if not applicable.

Additional concerns, requests, comments

PERMISSIONS, AGREEMENTS, AND CONSENT

PERMISSION AND RELEASE FORM

I, parent/guardian of the youth named in this registration form, grant permission for them to attend this retreat and do hereby release the above regional entities and ministries from liability involving child/ren named in this registration form when participating in this retreat.
I grant the the above regional entities and ministries, the right, if necessary, to provide for emergency medical treatment of my child should such a need arise. Likewise, I release sponsors and regional representatives from liability in the event of any accident related to this event and hold them harmless from damages.

I have read and agree to the permission and release form above.

TRANSPORTATION AUTHORIZATION

I, parent/guardian of the youth camper(s) in this registration form, grant permission and do hereby release the above regional entities and ministries from liability involving child/ren named in this registration form when participating and accompanying the above regional entities and/or ministries on activities such as transportation to and from retreat locations. I release the above regional entities and ministries, staff, and Regional Representatives from liability in the event of any accident related to this event and hold them harmless from damages.

I have read and agree to the permission and release form above.

MINOR MEDICAL AUTHORIZATION

The above regional entities and ministries and their staff may give my child/ren Tylenol, Ibuprofen, Benadryl, and or a topical solution to treat them for minor aches, pains, and ailments as they become evident. The staff or a medical professional on call will administer all medications in accordance with the manufacturer's directions.

I have read and agree to the minor medical authorization form.

EMERGENCY MEDICAL AUTHORIZATION

I, parent/guardian of child/ren named in this registration form hereby authorize the above regional entities and ministries and their staff to seek and authorize emergency medical treatment for youth campers named in the registration form. This includes anesthetic, medical treatment, and the performance of whatever operations or removal of tissue decided to be necessary by the attending physician(s).

I have read and agree to the emergency medical authorization form.

WALTER SCOTT CAMPER PLEDGE

Camper: I agree to participate fully in the retreat program, to cooperate with the camp leaders, and to attend the entire event. I will not bring firearms, knives, food, fireworks, electronic games, alcohol, drugs (except those listed under health information), or any other items that may be illegal or with the intent to cause danger to myself, those around me, or our surroundings. I will adhere to regulations regarding usage of cellphones and other electronic devices as implemented by staff. Furthermore, I understand that the above regional entities and ministries stand against bullying in every form and, therefore, I will treat others with respect and not engage or tolerate bullying. I understand that if I do not abide by this pledge, I may be sent home.
Parent/Guardian: I have discussed with my child/ren what is and what is not appropriate to bring to the retreat as well as discussed with them that bullying is inappropriate and will not be tolerated. I fully understand that should my child/ren commit a serious infraction of retreat guidelines, I will arrange to remove my child from the retreat at the request of the retreat or regional staff.

Both parent/guardian and camper(s) have read and agree to the permission and release form above.

MEDIA RELEASE FORM

The above regional entities and ministries, and their staff or designated agents may photograph or record activities, including retreat attendees, during the retreat program.

I consent to the use of any video, images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of my child/ren during events at the retreat to be used, distributed, or shown for promotional or other purposes.

I have read and agree to the media release form

Checking the consent boxes above represents your digital signature and authorization.

Coupon Code

Billing Information

Name

Credit Card

Visa
Mastercard
American Express
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Address

Mobile Phone Number