Fall Retreat 2019 Student's Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Student's Age (choose one)*12131415161718Student's Grade (choose one)*6th7th8th9th10th11th12thStudent's T-shirt size*adult smalladult mediumadult largeadult extra-largeadult 2x-largeStudent's sweatshirt size* adult small adult medium adult large adult x-large adult xx-large Gender of student*MaleFemaleParent's Name* First Last Emergency Contact (name and phone number)*Parent's Email I understand that the cost for a RUSH Student is $40 and the cost for a guest is $40. (A registration form will need to be filled out by each guest student.) Scholarships are available contact Chris Smith if you are interested.*YesNoI (Student) agree to the following guidelines for the weekend. (You will need to check each box to confirm that you agree.)* (1) Stay with my group and agree to be transported only by them and will not leave unless I have pre-approved permission from my parents and Chris. (2) Be respectful of my host and follow their requests. (3) Pay attention and participate during the sessions and be respectful of my leaders. (4) Have an incredible time and will seek to be an example to others in all that I say and do. Parents: By typing your name in the following boxes confirms that you agree to paying the fee (Scholarships are available. Contact Chris if you would like to apply) and all of the rules presented to your student.* First Last Student: By typing your name in the following boxes confirms that you agree to all of the rules presented.* First Last PhoneThis field is for validation purposes and should be left unchanged.