Black Campus Ministry Spring Retreat Feb 11-13th,
2005
Registration Form
DUE: Monday, FEBRUARY 7th, 2004
Forms can be returned to Campus Ministry in
McElroy or to Yaw Anyinam in 90 St. Thomas More contact him at 5-0827
Please print.
Personal Information
Name_______________________Middle ________________________Last________________________
School Address____________________________________ School Phone____________________
Cell Phone:_________________________________
Emergency Information
In the event of an emergency and the primary contact is not available,
please notify and give the following individuals.
Name 1_____________________ Address:_______________________
Phone: (_____)_________________
Name 2_____________________ Address:_______________________
Phone: (_____)_________________
Name 3_____________________ Address:_______________________
Phone: (_____)________________
Medical Information
Doctor________________________________________ Clinic Name___________________________
Address_______________________________________ Phone (______)________________________
Insurance______________________________________ Policy Number_________________________
Special Needs
Please list any allergies or food restrictions you may have.
___________________________________________________________________________________________
Payment
The cost of attending the retreat is $30.
Payment plans are available for all those who feel that the registration
fee cannot be fulfilled by the deadline.
All plans must be approved by Yaw Anyinam at 5-0827.
Fee enclosed___________ Payment Plan __________ (please
leave a contact number)
Authorization
Along with my registration form, enclosed is the $ 30 fee or my payment
plan agreement. My signature below
confirms that all information provided on this registration form is
current and accurate. I ensure that this information
was voluntarily provided to ensure my safety during my attendance at
the BCM Spring Retreat.
Signature___________________________________________________
Date___________________