Join the youth of BASIC & ROC Ministries as we head to another wonderful memorable yearly Retreat at:

953376 7th Line EHS, Mono, Ontario, L9W 2Z2

The Valley of the Mother of God

REGISTER SOON AS SPOTS ARE LIMITED THIS YEAR!!!!

You do not want to miss out! Come and invite others to the Retreat from: Saturday March 9th - Tuesday March 12th, 2013. Fee: ** 150 $ per Person. **270 $ for Siblings ROC: Grades 5-7 BASIC: Grades 8-1st Year University Upon registration, you will be sent an informational package on what to bring, how to prepare and what to expect. Dont miss out on this life changing and unforgettable experience! REGISTER NOW!
For more information contact: Nabil (647)885.0533 Melina Dulluku nabeel_mansour@hotmail.com melsays_gotochurch@hotmail.com

Sandrine (416) 878 6394 bornagain_2004@hotmail.com

Personal information:
First Name:___________________ Last Name:___________________________ Home phone #:______________ Cell phone #: ________________________

Address:____________________________ Apt #:___________ City:____________________ Province:________ Postal Code:___________ Parent Email: (Confirmation will be sent to this email address) _______________________________________________________ Retreaters Email: (confirmation will be sent to this email address as well) _______________________________________________________ Birthday: ___________________ School Grade You are In_______ Gender: Female or Male Child or youth lives with: __Both Parents; __ Mother; ___ Father; ___Guardian; ____ Foster Parent. Mother/Guardian :(full name)____________________________________ Father/ Guardian: (full name_____________________________________ Cell#:_____________ Cell#: ____________

3rd Party Emergency Contact:________________ Relation to student:__________ Phone #:______________ How did you learn about this retreat? ________________________ Who referred you to this retreat? _____________________________ Have you attended March Break Retreat with us before? IF yes then when?__________________________

Medical Information:
Health Card#: ________________________________ Health and Safety: are emphasized at all times during the retreat Medication: Does your child have any conditions (mental, physical or behavioral) that require medication to be dispensed at the retreat? _____________________ please attach a note to inform us of the time of the medications and proper way to administer the medication.

Allergies: please list any kind of food, or medications or environmental things that your child is allergic to: ___________________________________ Does your child carry an EpiPen? ________________ If yes, then please make sure there is one with your child and another one for emergency submitted to (Nabil or Sunny) the day of the retreat please. Over the counter medication during the retreat: we keep with us the following medications for emergency use for the youth to be dispensed at the discretion of the pharmacist with us on the retreat. Please indicate with an X mark if it is permitted to give your child the following medication if needed. _____ Cold and Sinus ____ Tylenol ________ Benadryl _________ Gravol _________ Motrin ______ Advil ____ (Antacid)

___ Imodium (kids over 12 years old)

I give permission for _______________ (name of your child) to be given any of the above checked medication if required. Please sign beside the X: __________________________.

Authorization for treatment:

1.

I _____________ authorize CAFM personnel to handle any medical problems with my child during his/her stay at the retreat. In case the child requires special medications, x-ray, or any kind of treatment beyond that which is possible at the retreat, we will call to notify the parent immediately and the parent will be responsible for any additional expenses for the care of the child or transportation. I ______________ will inform (Nabil or Sunny) if my child has had any communicable disease within 3 weeks before his or her departure to the retreat.

2.

3.

Signature of the parent/Guardian_____________________ Date: ___________________

This is to certify that I, the parent of the above mentioned child, allow for his/her presence at The Valley of the Mother of God, commencing on March 9th to March 12th, 2013. I understand the terms of his/her presence and will pay the above mentioned costs via cash or cheque with the understanding that boarding, meals and transportations costs will be covered for my child.

_____________________________________________
Parent Guardian Signature

________________________
Date