Winter Retreat Registration Form

All Winter Retreats are held at Camp Timber-Lee, East Troy, WI

Departure will be at 3:00 PM on Friday, January 3rd..

See IMPACT staff for brochure.

For more information text/call Mat Kalvelage (402) 741-0447

You must register each participant separately.

Participant's Name

First Name

Last Name

Winter Retreat Sign up

JrHi WinterXtreme Jan 3-5, 2025

Sex

Male

Female

Participant's Age

Birthday

Which parent/guardian should we communicate with?

Father

Mother

Guardian

Father’s or Guardian’s Name

First Name

Last Name

Father’s Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father’s Cell Phone

(###)

###

####

Mother’s or Guardian’s Name

First Name

Last Name

Mother’s Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother’s Cell Phone

(###)

###

####

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

Food Allergies? (Please list all or write NONE)

Physical Restrictions? (Please list all or write NONE)

Medical, mental, emotional alerts? (Please list all or write NONE)

Prescription medications? (Please list all or write NONE)

Winter Retreat Registration Form

Community Bible Fellowship

Service Times