Trailhead Registration

FEBRUARY 21-23, 2025
AGES 12 to 22
Table rock camp & Retreat Center

Complete EVERY question listed on form below and be prepared to provide a $70 reimbursement fee for costs associated with attending the weekend event. If you have no specific answer for a question, simply add "NA" in the response area. Failure to answer ALL questions or provide the $70 reimbursement fee will hinder your ability to attend. Once you are registered, you will be contacted by your local CEF office with further details.

ABOUT YOU

Where do you live? *

How did you learn about CYIA Trailhead Weekend? *

Student Name: *

Student Age: *

Student Class/Grade: *

Birth Gender: *

Male Female

Student Street Address: *

Student Email: *

Father/Guardian Name: *

Mother/Guardian Name: *

City, State, & Zip: *

Student Church: *

Father/Guardian Phone: *

Mother/Guardian Phone: *

Student Phone: *

Student Pastor / Youth Pastor: *

Father/Guardian Email: *

Mother/Guardian Email: *

Medical informatioN

Should student's activities be restricted for any reason? *

Yes No

If YES, explain and provide restrictions: *

List any major illness this past year: *

Date of last Tetanus shot: *

Does student wear: *

Glasses Contacts None

List any food allergies: *

List any medication/medical allergies: *

List environmental allergies: *

Food described reaction: *

Med described reaction: *

Environmental described reaction: *

Food required intervention: *

Med required intervention: *

Environmental required intervention: *

Medications: Please list all prescription and over-the-counter medications taken routinely. We will administer medications to students upon request or instruction from parent/guardian. Prescription medications must be in their original packaging/bottle that identifies the prescribing physician, the name of the medication, the dosage, and the frequency of administration. **Please Note: If your student has been prescribed an Epi Pen, make sure it is labeled with their name and they bring it with them to be given to the nurse.

Does student take medication? *

Medication: *

Dosage: *

How often? *

Taken to treat? *

INSURANCE INFORMATION

Primary Medical Insurance Company: *

Policy Holder's Name: *

Policy No: *

Medical Insurance Address: *

Policy Holder's Address: *

Group No: *

Medical Insurance Phone: *

Policy Holder's Phone: *

Consent

Submit Registration / Authorization

REGISTRATION

FEBRUARY 21-23, 2025AGES 12 to 22Table rock camp & Retreat Center

ABOUT YOU

Medical informatioN

​INSURANCE INFORMATION

Consent

FEBRUARY 21-23, 2025
AGES 12 to 22
Table rock camp & Retreat Center

INSURANCE INFORMATION