MAXlife Fall Retreat

Payment Options and Add-ons

Base Cost ($115.00)

Base Cost includes all food, lodging and activies except the following. Check any activity you want to add to your registration.

ADD PAINTBALL ($28.00)

Paintball in Not included in retreat cost. Cost includes gear, paint, and 2 hours of play.

ADD HIGH ROPES ($28.00)

High Ropes in not included in retreat cost. Cost includes gear and 3 hours of high ropes activities.

STUDENT INFORMATION

Student Name

Student Gender

Male
Female

Student Grade

6th
7th
8th
Volunteer Leader

Student Date of Birth

Students MAXlife Coach (if known)

Parent Email (optional)

Name Of Two Friends On The Retreat (it is our goal to room you with at least one friend)

Dietary Needs

***MAXlife MIDDLE SCHOOL MINISTRY does not control the food for this retreat. Dietary need information is to help us in case of an emergency. Please contact the camp directly to address any severe dietary issues the kitchen staff needs to know about.

Phone: 704.938.1314
Email: [email protected]

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name

Confirm Email

Phone Number

Address

Important Stuff We Gotta Ask

Medical Insurance Company

Policy Holder Name

Group Number

Plan or Policy Number

Medical Insurance Company Phone Number

Family Physician Name

Family Physician Phone Number

List Any Applicable Physical Limitations (Asthma, diabetes, allergies, etc.), And/Or Special Instructions

List All Medications You Plan To Bring To The Fall Retreat

*If your student takes medication you will turn all meds in at check-in. Cabins leaders will have all medication for that cabin. Make sure you have all medication(s) in a ziplock bag, with an index card with students name, when to take meds and detailed instructions about medication that the cabin leader may need to know. .

Emergency Contact Name

Relationship To Student

Emergency Contact Cell #

Secondary Emergency Contact

Relationship To Student

Secondary Emergency Contact Cell #

Legal Stuff The Lawyer Makes Us Do

Please read the Meck Liability Waiver and sign to agree to the terms.

I, the undersigned, agree to the terms above.

Legal Stuff For The Camp

Please read the following Liability Waiver for Cedar Grove Retreat Center, agree to the terms, and sign where indicated.

Cedar Grove Retreat Center
Challenge Course, Water Activities, Paintball, Climbing Wall & other Recreational Activities Acknowledgement of Risk and Assumption of Responsibility / Liability Waiver / Hold Harmless

Cedar Grove Retreat Center offers a variety of activities that often include exercises, activities, group initiative problems, low element challenges and high element challenges like the climbing wall, among other activities. Participants engage in adventure activities always by their own choice, so the individual must assume the risk of injury. We do not want you to engage in activities that would be detrimental to your health or which might be opposed by your physician because of illness, injury or surgery. We ask you for the following information so we can better help you safely enjoy your experience. Thank you for your assistance!

I understand that during my participation in Challenge Courses, Paintball, Climbing Wall, Boating, Swimming or other Activities, I may be exposed psychologically and physically to stressful and challenging situations. I understand, too, that although the center has taken precautions to provide proper organization, supervision, instruction, and equipment for each activity, it is impossible for the center to guarantee absolute safety. I understand and appreciate that there are a number of inherent risks involved in these activities that are beyond the control of the camp or its staff and agree to personally assume such risk. Also, I understand that I share responsibility for safety and I assume that responsibility. Further, I waive any claim that may arise against Cedar Grove Retreat Center, Capstone Climbing and Adventure Inc. or its employees as a result of my participation in any activity. I accept responsibility for my personal health and verify that I have no physical or psychological problems that would prohibit my participation in the activity. I agree to comply with all instructions and directions of Cedar Grove Retreat Center, Capstone Climbing and Adventure Inc. or its staff during my participation.

I Agree To The Cedar Grove Retreat Liability Terms Explained Above.*

Please read the Cedar Grove Liability Waiver and sign to agree to the terms.

I, the undersigned, agree to the terms above.

Like To Scholarship A Student? (Not tax-deductible.)

Give the gift of registration with a voucher for a friend

Amount$

Recipient Email

We will send an email with the voucher code. It will expire on September 30th, 2019.

Add Voucher

Running Total

$115.00

Coupon Code

Total

$115.00

Refund Policy*

By checking this box, I acknowledge that all payments (including activity payments) are non-refundable after September 12. We pay the camp for the students who sign up, so even if you realize you can no longer attend or if you back out of an activity, we still pay for your spot. That is why payments are non-refufundable.

Billing Information

Name

Credit Card

Visa
Mastercard
American Express
Discover

Address

This page is secured with 256 bit encryption