At the Wesley With a Center in mission Woodworth, LA emphasis!!

October 26th -- 28th, 2012 November 9th -- 11th, 2012 Check in Begins on Friday at 8 p.m. Retreat Ends Sunday at 11:30 a.m. COST is $85.00 per person Deadline for October 26th event: October 22st, 2012 Deadline for November 9th event: November 5th, 2012 Registrations/Changes after the deadline will be accepted on a space available basis only and you will be assessed a $30.00 late fee. Who is eligible? Any youth in grades 7 – 8 and Adult Workers with Youth There must be one adult counselor (21 years of age or older) for every one-to-ten youth participants, with a minimum of 2 adults per church. What to bring? Bible, money for YSF, comfortable clothing and your personal toiletry items (Linens, towels, etc. will be provided by the Wesley Center.)

If you are unable to register online, Youth Event Registration please fill out the registration form 527 North Boulevard (one per person) and mail to: Baton Rouge, LA 70802 225-383-3144 FAX

Please select by circling your choice: Event #1 October 26-38, 2012 PLEASE PRINT Event #2 November 9-11, 2012

NAME ______

ADDRESS ______

CITY ______STATE ______ZIP ______

HOME PHONE ______ALTERNATE PHONE ______

EMAIL ADDRESS ______

DISTRICT ______CHURCH ______

 Male  Female Grade ______ Youth  Adult

 All Adults must have taken Safe Sanctuaries and had a background check. In the event of an emergency where medical treatment is required, I give my permission to the event staff or church sponsor to obtain competent medical services. Please attempt to notify me immediately concerning any such emergency.

Signature ______Date ______(Parent or legal Guardian) Insurance Company ______Policy Number ______Medical Comments, Allergies, Current Medications, etc.______

______

______

______Visa MasterCard # ______Exp. Date ______

Credit Card Amount $ ______Name on Card ______Check Amount: $ ______Check #: ______Each person attending must read and sign the CCYM Covenant: Our Covenant of Behavior for Louisiana CCYM Events I agree as a participant in a Louisiana Conference Council on Youth Ministry event to follow certain standards. I will not bring nor consume/discharge alcohol, tobacco, illegal drugs, fireworks, or firearms, nor will I engage in inappropriate sexual behavior, or intentionally cause the destruction or abuse of any person or property. Electronic devices such as games, phones CD/MP3 players, etc. are to be used only during free time and in a manner consistent with the purpose of this event. (i.e. no profane, violent, drug related or sexually explicit material.) I am responsible for the security of any personal property and will be responsible for any loss or damage. The Wesley Center will be providing my meals. I am not to have food sent or delivered to this event. I agree to follow the daily schedule at all times, and at no time will I leave the event site. I understand that there will be no visitors allowed (including family and relatives) while this event is in progress without prior approval of Director and that there will be no visitation in rooms designated for the opposite gender whether youth or adult. If I should not act in accordance with this covenant, I realize that I may be disciplined at the event director's h r j discretion, up to expulsion from event, suspension from the next two Louisiana Conference Youth events and the

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assumption of legal or financial liability. By my signature on this registration form, I am indicating that I have read - 6 1 this covenant and accept my end of the agreement, with the expectation of an event experience leading to my - 8

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spiritual growth and enjoyment. s i v Adult counselors have the primary responsibility for behavior of their group & agree to follow the same e R covenant of behavior as the youth.

Agreement: The following signatures indicate both participant and parent/guardian (if applicable) agree to enter into the Covenant as printed in this brochure, and that this “Registration Form” and all event information has been read and understood.

______Participant Signature and Date Parent/Guardian Signature (if applicable) and Date

______Pastor or Youth Director/Coordinator Signature and Date

YSF STORE ITEMS/PRICES: YSF AUCTION: Sweatshirts $15.00 (X sizes $18.00) Baked Goods T-shirts (short sleeve) $8.00 (X sizes $10.00) Signed retreat memorabilia T-shirts (long sleeves) $13.00 Hats $10.00 Sunglasses Pajama Pants $20.00 Snuggies with booklight $25.00 Pillow Pets Candy Grams