Phone # where someone can be reached in case of emergency _________________
Address__________________________________________________________________
School Grade________ Sex_______ Age_______
Do you have any allergies or special medication requirements we should know about? Please list:
___________________________________________________________________________
Parent’s signature _________________________________
What church do you attend _________________________________
FOR REGISTRAR ONLY:
Building _____ Room _____
Fee for retreat -- $45 
If paid by April 4 -- $40.00
NOTICE: Parental Approval and Waiver of Claim
I hereby approve the retreat application and certify to its correctness and expressly waive any and all claims against Cherry Run Camp, or any of its District Boards or representatives because of any injury or other damage that may be incurred to my child or property in connection with or incident to the Cherry Run Youth Retreat at Rimersburg, Pa. I also authorize the camp nurse and staff to administer medical aid and treatment to my child as needed.
Signature of Parent or Guardian__________________________________________
SEND REGISTRATION TO:
Beckey Addleman
P. O. Box 33
Shanksville PA 15560
Make checks payable to: Cherry Run Camp
NOTICE: the Youth Retreat brochure can also be downloaded in .pdf format -- just slip on over to Cherry Run Youth Retreat 2009
