Facebook Flocknote

Online Teen Registration and Payment

- Please note: Although we prefer online registration, if you need a mail in form, you can get one here.
  
  Please complete the following form to finish your registration
  for the
  TEENS ACTS Retreat
  
  (All Information will be kept confidential)
  
  For teen retreat or registration information contact Rebecca Vincent at 806-570-9578.
  or
  eMAIL
  
  Final Payments for the retreat can be made by clicking the button below!
  (This is only if you have already completed the form below and paid the deposit payment!.
  Final Payment
- The maximum number of form submissions has been reached. This form is currently not available.
  
  Select Retreat
  
  Which Retreat are you registering for? REQUIRED Please fill out this field.
  
  Are you Registering as a Retreatant or Team Member? REQUIRED Retreatant ACTS Team Member Please fill out this field.
  
  Registration Form (Part A)
  
  Payment Verification REQUIRED I will pay the $100.00 deposit which leaves a balance of $100.00 owed I will pay the $200.00 fee in full Please fill out this field.
  
  Email Used on Paypal REQUIRED Please fill out this field. Please enter valid data.
  
  Participant's First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Participant's Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Name teen would wish to be called by? REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter valid data.
  
  Home Phone REQUIRED Please fill out this field. Please enter valid data.
  
  This information is required!
  
  Teen's E-Mail Address REQUIRED Please fill out this field. Please enter valid data.
  
  This information is required!
  
  Teen's Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  Sex REQUIRED Male Female Please fill out this field.
  
  Grade REQUIRED Please fill out this field.
  
  Graduation Year REQUIRED Please fill out this field. Please enter valid data.
  
  School REQUIRED Please fill out this field. Please enter valid data.
  
  Is participant a practicing Catholic? REQUIRED Yes No Please fill out this field.
  
  If so What Parish/Church? Please enter valid data.
  
  City of Parish/Church Please enter valid data.
  
  T-Shirt Size (Adult Sizes) REQUIRED Please fill out this field. Please enter valid data.
  
  Parent or Guardian's Name REQUIRED Please fill out this field. Please enter valid data.
  
  Parent/Guardian's Home Phone REQUIRED Please fill out this field. Please enter valid data.
  
  Parent/Guardian's Business Phone Please enter valid data.
  
  Parent/Guardian Cell Phone Please enter valid data.
  
  I, REQUIRED Please fill out this field. Please enter valid data.
  
  grant permission for my teen, REQUIRED Please fill out this field. Please enter valid data.
  
  to participate in this youth ministry event including transportation as required. This activity will take place under the guidance and direction of adult and youth volunteers of the ACTS Community. REQUIRED Please fill out this field. Please enter valid data.
  
  Medical Consent and Permission to Treat (Part B)
  
  To the best of my knowledge, my teen REQUIRED Please fill out this field. Please enter valid data.
  
  is in good health, and I assume all responsibility for the health of my teen. Emergency Medical Treatment: In the event of an emergency, I hereby grant permission to transport my teen to a hospital for emergency medical treatment. REQUIRED Yes No Please fill out this field.
  
  Preferred Hospital REQUIRED Please fill out this field. Please enter valid data.
  
  I wish to be advised prior to any further treatment by the hospital or doctor. REQUIRED Yes No Please fill out this field.
  
  If you are unable to to reach me, please contact: REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to me or my Teen REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number of Contact Person REQUIRED Please fill out this field. Please enter valid data.
  
  Medical Information
  
  Insurance Carrier REQUIRED Please fill out this field. Please enter valid data.
  
  Insurance Policy Number REQUIRED Please fill out this field. Please enter valid data.
  
  My teen is taking medication and will bring all of the medicines in their original containers REQUIRED Yes No Please fill out this field.
  
  I hereby grant permission for non-prescrption medication (such as cough drops, cough syrup, tylenol...etc) to be given to my teen if necessary REQUIRED Yes No Please fill out this field.
  
  I understand that asprin will not be given to my teen without express permission. I hereby grant such permission: REQUIRED Yes No Please fill out this field.
  
  My teen is allergic to the following: REQUIRED Please fill out this field.
  
  My teen's immunizations are current and up to date. REQUIRED Yes No Please fill out this field.
  
  My teen's last tetanus/diphtheria immunzation was on REQUIRED Please fill out this field. Please enter a date.
  
  My teen has the following physical limitations REQUIRED Please fill out this field.
  
  My teen has the following restraints: bed wetting, fainting...etc. REQUIRED Yes No Please fill out this field.
  
  If yes, please explain
  
  My teen has recently been exposed to a contagious disease or condition such as mumps, measles, chickenpox...etc REQUIRED Yes No Please fill out this field.
  
  If yes, please state the date and disease or condition
  
  My teen is suffering from a psychological condition which may affect or limit his or her ability to participate in this activity. REQUIRED Yes No Please fill out this field.
  
  If yes, please explain
  
  Parent/Guardian Signature REQUIRED Please fill out this field. Please enter valid data.
  
  Final Payment: A deposit of $100 will guarantee your spot for the retreat. Full payment must be received on or before the date of the retreat. If only paying your deposit today, please visit our payment page to make your final payment.
  
  Payment Type REQUIRED 100.0 – Deposit 200.0 – Full Payment Please fill out this field.
  
  Total:
  
  Submit
  
  Proceed to Payment
  
  This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Online Teen Registration and Payment

Please note: Although we prefer online registration, if you need a mail in form, you can get one here.

Please complete the following form to finish your registration for the TEENS ACTS Retreat

Please complete the following form to finish your registration
for the
TEENS ACTS Retreat