DOVE USA Youth Winter Retreat Registration

Please acknowledge the following before beginning:*

Got it!

Date of Retreat: March 12-14, 2021
Location: Refreshing Mountain Camp
Cost: $130* - includes lodging, food, and a cool t-shirt 🙂

Arrival is between 6:30-7pm on Friday, March 12th. Activities begin at 7:30pm.

*Payment will be made separately from this application on a due date specified by your local youth leader.

I will be attending Winter Retreat as a _________ .*

Student
Youth Leader / Volunteer

Personal Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender*

Male
Female

Home Church:*

T-Shirt Size:*

Youth Leader/Volunteer Information

Email*

Mobile Phone*

Is there anything that you have dealt with in your history that we ought be aware of that would inhibit your ability to lead youth effectively?*

Youth Leader/Volunteer Agreement*

I agree to be a living example of Jesus to the youth of Winter Retreat.

As a leader at Winter Retreat, you will expected to set the tone and lead by example throughout the weekend. This means that you commit to living above reproach, with high character, and integrity in all areas of life. Making it a priority to love God and love others with all of your heart. Looking to Jesus Christ as the model of conduct for the entirety of your time serving at Winter Retreat. If you cannot uphold this commitment, we request that you not serve at the retreat.

Youth Leader/Volunteer Signature*

Student Information

Birth Date:*

Age at time of retreat:*

Winter Retreat has been designed for students age 13-18. Please e-mail before continuing if you do not fall within this age range.

Applicant Email (if they have one)

Parent Name 1:*

First Last

Parent Name 2:

First Last

Parent Phone (Primary)*

Parent Phone (Back Up)

Parent E-mail:*

Youth Leader Information

Youth Leader(s) Name*

First Last

If you do not have a youth leader, please place 'N/A' in this field. Thank you.

Youth Leader(s) Email*

Please use the primary e-mail your youth leader uses to contact you. If you do not have a youth leader, please place '' in this field.

Medical/Insurance Information

Name of Insurance Carrier:*

Member Name*

First Last

Policy #:*

Physician Phone #

What medical or physical limitation should we be aware of that may affect your participating in any activity? (This information will be kept confidential)

Do you currently take any medications? (If yes, please list the medications and condition being treated)

Parental Consent

If you are under 18 years, your parent or guardian must complete the following:

Consent to Attend*

My child has my permission to attend the DOVE USA Youth Winter Retreat at Refreshing Mountain Camp in Lancaster, PA.

Medical Consent*

I agree to the following statement.

I consent to emergency medical treatment deemed necessary in the unlikely event of an accident. I will pay for any and all expenses incurred should insurance not cover them. I also release DOVE USA, the host ministry and staff from any liability resulting from any accident or illness. I will take full financial responsibility for costs incurred if my child needs to be sent home due to an emergency or misbehavior.

Parental Release and Indemnification Agreement*

I agree to the following statement.

DOVE USA, a Pennsylvania nonprofit organization with offices at 11 Toll Gate Road, Lititz, PA 17543 runs Winter Retreat in accordance with policies and values of DOVE USA.

We, the undersigned parent(s) or legal guardian(s) execute this Parental Release and Indemnification Agreement (Agreement) for and on behalf of the application-identified Child. We affirm that we hold legal status of parent or legal guardian of the Child. We understand that for the Child to participate in Winter Retreat, all parents and legal guardians of the Child shall execute the Agreement.
We agree that the Child will abide by the policies established by DOVE USA, and as enforced by DOVE USA in its sole discretion.
Both for ourselves and on behalf of the Child, we hereby assume the risk of activities that we or the Child engages in with Winter Retreat including risks encountered in sports activities and transportation for such activities. We hereby release, discharge, and/or otherwise indemnify DOVE USA and affiliated sponsors and organizations, their employees, volunteers and associated personnel [including the owners of property and facilities utilized for the program], from and against any claim, loss or damages by or on behalf of us or the Child arising from the negligence of any DOVE personnel (including volunteers) or from our or the child’s participation in Winter Retreat activities or transportation.

We agree that to the extent we or the Child’s other parent(s) or legal guardian(s) is liable for any claim involving DOVE USA that we shall be held jointly and severally liable, together with the Child’s other parent(s) and legal guardian(s), for any liability arising from the Child’s participation in Winter Retreat activities or transportation.

We agree to assume full responsibility for any medical bills incurred, in the event any health insurance we have or do not have would fail to cover the full cost of treatment, transport, or other emergency service incurred for the Child. Should DOVE USA in its sole discretion determine that the Child must return home before the group for medical or disciplinary reasons, we hereby agree to assume any costs for such travel, including costs for meals and accommodations.

Parent/Guardian Signature:*

By signing I affirm that I am the parent or guardian of the applicant and consent to each of the above statements.

Student Consent

The student applicant should complete this section of the application.

Acknowledgment of Cost : $130/person*

I understand that I will be expected to either fundraise or pay the full amount of Winter Retreat to my youth leader prior to attending Winter Retreat on the date that my youth leader elects. I am responsible for the cost, not my parents. If my parents choose to pay for me to attend, it is out of the graciousness of their heart and I will give them a big hug. Please make checks payable to 'your church'. Do not make payment directly to 'DOVE USA' unless specified. Thank you.

Student Consent for Dismissal or Disciplinary Action*

I understand and agree with the following statement.

Doing any of the following is grounds for dismissal from Winter Retreat:
1. Using alcoholic beverages, illegal drugs, or tobacco of any kind
2. Stealing or gambling
3. Pornography
4. Displaying any level of romantic or dating relationships - this includes holding hands, kissing, etc.
5. Going outside of the team housing area alone.

Doing any of the following is grounds for disciplinary action and possible dismissal from Winter Retreat:
1. Fighting, disorderly conduct, or excessive noise
2. Using profanity or temperamental outbursts
3. Listening to vulgar music or reading inappropriate material on your phone
4. Two individuals of the opposite sex alone
5. Not keeping your bed and items neat and clean
6. Disobedience to team leaders
7. Not keeping curfew

Student Signature*

By signing above I agree to the guidelines and rules of Winter Retreat. I also commit to living pure and staying positive throughout the event. I understand that this weekend has been designed to transform my life and I plan to give everything I have to loving God and loving those around me.

Section Break

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