1. REGISTRATION INFORMATION
Rally _________________________(Fall Retreat, Spring Rally, Summer Connection)Year _______
Chapter _______________________________________________
Complete this form for all attendees at the above named event (including all adults). This information will be
used for a roster (email and phone numbers only) to be distributed only to attendees unless indicated at the
bottom of the page.
NAME ________________________________ Name to be printed on nametag: __________________
ADDRESS ___________________________________________________________________________
CITY __________________________________________STATE _________ ZIP__________________
Please place a check next to the phone number you want printed on the roster:
HOME PHONE (__________) __________________________________________
CELL PHONE (__________) ___________________________________________
E-MAIL _____________________________________________________________________________
Circle all that are appropriate:
Male Female Birthdate ________ Grade in School _______
YOUer Sponsor Adult chaperone Yes / No -First time
Yes / No -Graduate (Age requirements: In order to attend a regional YOU retreat, YOUers must be in grades 9, 10, 11,
12 or equivalent, with a minimum age of 14 and a maximum age of 19; or, if not in high school, a
maximum age of 18.)
Yes / No - Vegetarian (Most camps can only provide no meat. If you have other dietary needs (ie. No dairy, vegan, etc.)
we may not be able to provide those.)
Yes / No - I want to participate in Secret Pals at this retreat.
Circle one T-shirt size: Small Medium Large X-Large XX-Large
Female sizes: Small Medium Large X-Large
My signature here certifies that I meet attendance and service requirements for this retreat.
Participant's Signature ___________________________________________ Date ___/___/___
My signature here indicates approval for my child to attend the above named Southeast Youth of Unity
event. I have read the Group agreements for this event and understand the consequence of inappropriate
behavior by my child will mean my child may be sent home at my expense.
*Parent's Signature _______________________________________________ Date ___/___/___
I do not give permission for this email and phone number to be printed in an event roster.
