Retreat - Upward Community

Upward Community’s 3rd Annual High School Girls Retreat- Supported by the Walder Foundation

Participant Legal Name(Required)

First Last

Participant Preferred Name/Nickname

Participant Birthdate(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Particpant Home Phone(Required)

Participant Cell phone(Required)

Participant Email(Required)

School Participant Attends(Required)

High School Grade Fall 2022(Required)

Room Requests(Required)

Participants are allowed to make 2 requests. Upward Community will do our best to place with one of the requests but does not make any guarantees:

Sweatshirt Size

Parent or Guardian 1

Name(Required)

First Last

Home Phone(Required)

Cell Phone(Required)

Email(Required)

Parent or Guardian 2

Name(Required)

First Last

Home Phone(Required)

Cell Phone(Required)

Email(Required)

Emergency Contact

Name(Required)

First Last

Relationship to participant(Required)

Home Phone(Required)

Cell Phone(Required)

Email(Required)

Pediatrician Info

Pediatrician Name(Required)

Pediatrician Phone Number(Required)

Any medication that participant will be taking during the weekend:(Required)

Yes

Please list the medication and describe what the medication is for(Required)

**Please note: Upward Community will not administer medicine or oversee it.

Anything staff should know about your daughter (anxiety for event, sleep issues, eating, etc)

Any known allergies (Food or medication)

Please sign your name to agree to the Health and Safety and Photo Release Waiver(Required)

Payment

Payment Type(Required)

Lump Sum - $180

Payment Plan - $60 x 3

If you would like a payment plan you can do 3 payments of $60.

Registration Fees(Required)

Price:

Registration Fees(Required)

Price:

Payment Mode(Required)

Online

Offline (Offline may only be used with Upward Staff PRE-Approval Only.)

Credit Card

Card Details

Cardholder Name

Name

This field is for validation purposes and should be left unchanged.