Edge and Life Teen Retreat Scholarship Registration

Student Information
Student Name
Student Name
Date of Birth
Date of Birth
Family Information
Primary Mailing Address
Primary Mailing Address
Primary Phone
Primary Phone
Emergency Phone
Emergency Phone
In case different from primary phone number
Father/Guardian Phone
Father/Guardian Phone
Mother/Guardian Phone
Mother/Guardian Phone
Scholarship Assistance Information
The cost of the retreat is $150. How much of these do you need waived to attend the retreat?
Student must be enrolled in the program and maintain a good attendance at the regular program. Student must have a demonstrated need for financial assistance. Generally a partial scholarship is given.
Please describe any situations that have contributed to your need for financial assistance.
Medical/Insurance Information
SEND ALL PRESCRIPTION MEDICATIONS IN THE ORIGINAL CONTAINER AND TURN IN TO THE ADULT IN CHARGE ON ALL TRIPS OR EVENTS REQUIRING THAT MEDICATION BE GIVEN IN THE PARENT’S ABSENCE.
Date of Last Tetnus Shot
Date of Last Tetnus Shot
Doctor's Phone
Doctor's Phone
Code of Conduct Affirmation
By clicking below, you attest that each member agrees to the terms and conditions below: I request that the above named student be allowed to attend church related events, trips, socials and service opportunities with Resurrection Church. In the event of illness, I request that the designated volunteer or youth minister obtain medical treatment on my behalf for my student if I or the emergency contact named above cannot be reached. I understand that reasonable precautions will be taken to safeguard the health of my teen and that I will be contacted immediately in case of emergency or accident. I will not hold Resurrection, the Diocese of Phoenix, the chaperone, or youth minister responsible. My student named above will dress and act respectively; use no verbal or physical abuse of self or others; will not have in their possession at any time, alcohol, drugs or tobacco of any kind; will be responsible for their own belongings; will not leave the designated area at any time for any reason without contacting the adult in charge; and will review these guidelines with me prior to signing below. I understand that if the teen named above is involved in any illegal activity or serious destructive behavior that I will be contacted immediately and responsible for their immediate transportation home.