2026 SFB MIDDLE SCHOOL SUMMER RETREAT REGISTRATION...SCROLL TO BOTTOM FOR DETAILS

REGISTRATION FORM:

Student Name

Student Email

Student Phone

Parent/Guardian Name

Parent Email

This address will receive a confirmation email

Parent Phone

Address

TSHIRT SIZE

ADULT LARGE ADULT MEDIUM ADULT SMALL YOUTH XL (12-14Y) YOUTH LARGE (10-12) YOUTH MEDIUM (8-10y)

EMERGENCY CONTACT /MEDICAL RELEASE

EMERGENCY CONTACT:

EMERGENCY CONTACT RELATION TO STUDENT

Phone

List all Student Allergies and/or Medical Concerns or type NONE

Please List any Medications coming with your student or type NONE

INSURANCE PROVIDER

GROUP #

MEMBER ID or STUDENT SSN

PARENT PERMISSION AND STUDENT AGREEMENT

Parent/Guardian, by entering your name below, you agree to hold Silverton First Baptist Church staff, and any other associated parties harmless in the event of bodily injury or harm [including, but not limited to, death]. You also give Silverton First Baptist Church permission to administer/authorize medical care in any fashion and by any party whom they deem suitable -and- you authorize any medical facility, urgent care facility, or health care professional from which your student receives care between the dates of August 21st – August 24th 2026 to release health information to Silverton First Baptist Church/Youth Staff Members. This authorization is for information which pertains to any condition which develops or occurs between these dates and may be contained in medical or mental health (other than psychotherapy notes) records. It includes (but is not limited to): Admissions, or Discharge Summaries, Pathology Reports, EKG Results, Progress Notes, Laboratory Reports, Dental Records, Operative Reports, Radiology and other Diagnostic Images and Reports, Emergency Medicine Reports, History and Physical Exams, Consultations/ Evaluations and Outpatient Clinic Records. This release expires on August 25th, 2026 12:01 AM unless revoked in writing sooner. NOTICE: Many organizations and individuals such as physicians, hospitals and health plans are required by law to keep your health information confidential. This authorization allows those “covered entities” to release your health information to Silverton First Baptist Church / Youth Leadership Staff members, who may not be legally required to keep your health information confidential, in which case it will no longer be protected by state or federal confidentiality laws. If you, the PARENT /GUARDIAN have granted permission and, if the medical information is submitted above is accurate, please type your initials and today’s date in the box below.

MY RIGHTS - PLEASE CHECK EACH BOX TO INDICATE YOUR UNDERSTANDING

I understand I may revoke the authorizations given at any time, provided that I do so in writing and submit it to Silverton First Baptist Church ATTN: Randy Mitchell PO BOX 1800 Silverton, OR 97381ion The revocation will take effect when Silverton First Baptist Church receives it, except to the extent that Silverton First Baptist Church or others have already relied on it. I understand that I am entitled to receive a copy of this Authorization from Silverton First Baptist church upon written request.

CONSENTING PARENT/GUARDIAN INITIALS and TODAY'S DATE

Parent Initials

STUDENT, IF YOU CHOOSE TO ATTEND, WILL YOU AGREE TO AND CHECK OFF EACH OF THE FOLLOWING:

Respect the requests of the leaders and abide by the rules given Leave your phone at home (or turn it in to the leaders on the first day to be used only in Emergencies) Treat your fellow students with kindness and respect Read through the list of things not to bring (listed below) and refrain from bringing any of those items with you

Student Initials Showing Agreement to Abide by Code of Conduct

PAYMENT (If not in full online now, we will settle in person later)

SOME OF THE DETAILS...

FRIDAY AUGUST 21st 3:00 pm - MONDAY AUGUST 24th 9:00 pm

6th, 7th, 8th, AND even our recent Middle School graduates going into 9th are welcome to come. SIGN UP ASAP to hold your spot!

"Home Base" will be at the Shetlers' house. Drop them off with their gear at 5326 Briar Knob Loop Scotts Mills, OR. The guys will camp out in the woods and/or use the cabin Joey built with his kids. Girls will be glamping in the Shetler home.

We will go on daily adventures.

We'll spend the Friday evening and Saturday up on the hill (Camp Dakota Ropes Course, Swimming and general shenanigans).

We will head to Canyon Drive park in Lincoln City Sunday.

We will finish on Monday with a trip to Foster Lake for an entire day of boating! (Much more than last year...arriving at the lake earlier, staying later and getting a second boat on the water!)

We will have the students back to the church youth room for pick up Monday evening at approximately 9:00pm. We will text an ETA if it looks to be way off our original ETA.

More Details / Contact Information:
Shetler House Landline: 503-873-9335
Zach Richman Cell Phone: 503-798-0423
Pam Shetler Cell Phone: 503-871-7077

WHAT TO BRING and WHAT TO LEAVE AT HOME home...

WHAT TO BRING

•Bible, Notebook & Pen
•Snacks to share for the first night
•Tent (we may not need it, but let us know if you have one that sleeps 8-10)
•Sleeping Bag & Pillow
•Shower Gear & Shower Towel
•Flashlight
•Camera that doesn’t connect to internet or data... (Please have your student leave their phones at home. We will ask that the kids turn in any cell phones that come with them. If you would like to contact your child at anytime, feel free to connect through a leader phone and at anytime your student might wish to contact you, a leaders phone will be provided.)
•Warm & Cold Clothes
•Reusable/Labeled Water Bottle
•Life Jacket (will be required for anyone wishing to go into the water at the beach AND for boating. If you have extra please send them, if you don't have any, please let us know so we can work on making sure we have enough)
•Beach Towel
•Boogie boards and other fun things for the beach
•Sunscreen & Modest Swim Wear *
*Please send them with something that will provide good coverage for active play. We request one piece if possible, but tankinis with full coverage are great!

WHAT NOT TO BRING

• Illegal Stuff
• Legal But dangerous stuff including, but not limite to, Crummy Attitudes
•Electronic Devices (Phones*** etc.)

***LEADERS WILL HAVE PHONES THROUGH WHICH PARENTS MAY TEXT THEIR STUDENTS AS NEEDED AND VICE VERSA. Please feel free to contact us if you have questions about this policy.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2026 SFB MIDDLE SCHOOL SUMMER RETREAT REGISTRATION...SCROLL TO BOTTOM FOR DETAILS

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