PK Retreat – September 23 & 24, 2021 – Fond du Lac, WI

Host Church: The Sanctuary, 154 W McWilliams Street, Fond du Lac, WI 54935
Guest Speakers Jordan & Krista Herman

Thank you to our Sponsors: The Sanctuary, WI Youth Ministries, & WI Ladies Ministries
For Info: Sis Pace’s Cell 920-517-8250

Friday Saturday
3pm Registration, Coffee Shop, Games 9:00am Breakfast
4:45pm Dinner 9:30 am Trip to Little Farmer (Weather permitting)
5:45pm Worship/Commitment Service 1:00pm Lunch
7:30pm Prep to Leave for the Park 1:30 pm Split Session
8:00pm Fondy Sports Park, Mini Golf & Go Carts 2:15 Q & A
10-12am Games, Snacks, Fun Times 3:00pm Dismissal
*We understand that we all have very different, very busy schedules. If you need to arrive late or leave early, we understand. You’re welcome for all or part!!!

Guidelines
Retreat is for students ages 11 to 18 years. Students over the age of 18 must have specific permission to come as helpers.
Relax and have fun - Dress Casual
Bring: Bedding, Pillow, Modest PJs, Overnight bag, Air mattress if desired & Bible.
Open your heart & mind to hear from God - We’re going to be here for a couple days so keep it cleaner than your room at home ☺

Registration Info: (All registrants must be children of a licensed UPCI minister. Registration fee is $25 for 1st PK, $20 for each sibling.)
Name Age Birth Date Male/Female PK Signature
________________________ ____ ____________ _____________ ___________________________

________________________ ____ ____________ _____________ ___________________________

________________________ ____ ____________ _____________ ___________________________

________________________ ____ ____________ _____________ ___________________________

Name of Parent Address City State Zip

____________________________________________________________________________________________
Cell Phone # Date
_________________________________________ ________________

Statement of Health and Medical Release

By my signature below, I grant permission for the above named children to attend the WI District PK Retreat at The Sanctuary of FDL, on
Sept 23 & 24, 2022.
Is there any activity in which you do not wish your PK to participate or any information regarding welfare, restrictions, diet, etc.,
NO / YES (please explain)______________________________________________________________________________

Release of Liability
I hereby release, remise, and forever discharge from any claims and liabilities whatsoever, without limitations, that I may have against
the Wisconsin District UPCI, its officials, The Sanctuary, and its officials, and any player who might injure my child, whosoever arising.

Emergency Treatment Permission

I do hereby state that I have legal custody of the minor child listed on this form. While this child is a registered attendee, I hereby
authorize any director or responsible person of said retreat to consent to any x-ray, examination, anesthetic, medical treatment, or
hospital care to be rendered to this minor under the general or special supervision and on the advice of a physician licensed to practice in
the state of Wisconsin, when such medical or surgical treatment is necessary.

Signature of Parent: ___________________________________________

If desired, you may print this form, fill out and text a picture to my cell, 920.517.8250. We look forward to hosting your PK!
Thank you, Sis. Pace