Remnant Retreat 2026

When: October 16th- 18th, 2026

Where: Arrowhead Bible Camp, Brackney PA

Cost: $200.00

*Please note This Form Must Be Filled Out By A Parent or Guardian*

*Any allergies your kids may have or medication they need to take and have with them on this trip*

Student Info

Name

Phone

Address

Parent or Guardian Info

I declare that I am the parent or legal guardian of the child named above and that the information provided accurate and true to the best of my knowledge

Confirm

First and Last Name

Emergency Contact Number

Insurance Info

I, the designated parent of guardian of this child, do hereby authorize adult workers with the youth of Grace AG to consent to any examination, x-ray, anesthetic, medical, or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said Hospital.

I agree

Yes

Insurance Company or Group

Policy Number

Name of Insurance Holder

Allergies + Medication info (Write N/A if this doesn't apply)

Transportation Agreement

I give Grace Assembly of God permission to transport my child/children to the designated event on this form.

Yes

Payment Section

You may choose to either pay the total amount or select Contact me for Payment Plan Options.

Registration Payment

This is not required, however if you would like to make a donation to help sponsor another student in financial need you may choose any amount you would like to donate below. Thank you

Student Sponsorship

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

PARENTS/GUARDIANS please fill out this form and click submit.

Remnant Retreat 2026

Description

Please Fix the Following