2019 Youth Winter Retreat

Register Now!

Middle school and high school students, grades 6-12

 Friday, January 18 - Sunday, January 20

 Pine Springs Camp in Jennerstown, PA

 Our annual winter retreat with Peters Creek students and friends!  There will be games, good food, music, tubing (if there is snow, of course), Bible study, group meetings, hot chocolate, and a bonfire (again, counting on a bit of snow)!

How much:
 $110 (let us know if there is a problem)

Still have questions?
 Contact Pastor Dave or Jess Rubican, or call the church office at 412-833-6111.

**Once you submit your online registration, you will receive a follow-up e-mail on January 9th with more details about the 2019 Winter Retreat.**

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Permission for Emergency Medical Treatment:
By submitting this registration form, I do hereby give my permission for emergency medical treatment to be administered to the person who is the subject of this form.  I understand that all reasonable attempts will be made to contact me as soon as possible after the condition necessitating treatment arises and that, failing to reach me, all reasonable attempts to reach the person listed below as the emergency contact will be made.  I understand that every precaution will be taken for safety at all times.  I further release Peters Creek Baptist Church and the Pine Springs Camp and their representatives or sponsors from liability associated with any accident, injury, or disease to the person who is the subject of this form.


Paying Now or Later?

Student Information

*First Name
*Last Name
Apartment If Applicable
*Zip Code
*Home Phone (XXX-XXX-XXXX)
Cell Phone (XXX-XXX-XXXX)
*Birthdate (mm/dd/yyyy)

Parent/Guardian Information

First Name
Last Name
Home Phone (XXX-XXX-XXXX)
Cell Phone (XXX-XXX-XXXX)

Health Information

Health Insurance Company
Health Insurance Policy Number
*Known Health Issues
*Allergies and any medication you will be taking during the event

Emergency Contact Information

*First and Last Name
*Home Phone (XXX-XXX-XXXX)
Cell Phone (XXX-XXX-XXXX)

Grade & Shirt Size

Shirt Size

*Electronic Signature

*Participant Electronic Signature
*Parental Consent, by signing this I agree that I am the parent/guardian of this participating youth


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6300 Library Road | South Park, PA 15129
(412) 833-6111