Emerge High School Retreat Registration Form if paying with credit card

Name(Required)

First Last

Date of Birth:(Required)

Gender:(Required)

Dietary Needs/Allergies/Medical Restrictions:

Name(Required)

First Last

Relationship to Student:(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Emerge Registration Fee - $75(Required)

Deposit - $50

Total Fee - $75

Emerge Registration Total