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Contact Information

Address:
42409 Yarrow Central Road, Chilliwack, BC V2R 5C8

Phone:
604 316 4412

Contact Person:
Henry Schouten

Email Address:
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Links

Canadian Reformed Churches

Spindle Works

Deroche Retreat

United Reformed Churches

Registration Form

College and Careers Retreat

Full Name *
Please tell us your name.
Sex
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Email *
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Permanent Address
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City
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State/Prov.
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Postal Code
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Home Phone
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Cell Phone
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Birth Date
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Home Church *
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Emergency Contact *
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Emergency Phone No. *
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Click Here to see College Schedule
How much do you want to pay now *
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Cost to attend is $198.00 per person. A $50.00 non-refundable deposit must be included with the registration form. Full payment must be received by August 15, 2011. If you do not use Pay Pal please make cheques payable to: Deroche College Retreat. Mailing address: 7455 256 Street, Aldergrove, B.C., V4W 1V2. Please indicate if you have any special requirements, dietary or otherwise. Need more info. info@derochecollegeretreat.com
   
Please take the time to fill in the following medical information
Health Care Card Number *
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Family Doctor *
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Telephone # *
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Allergies
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Do you have any medical conditions that we should be aware of?
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Are immunizations up to date? *
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Are there any dietary concerns we should be aware of?
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All information on this form will be treated as confidential.
I wish to participate in the full camp program and all activities unless I advise otherwise in writing. I acknowledge that Deroche College Retreat reserves the right to dismiss a camper if it is in the best interest of the camper or the camp and that, in such a situation, the camp will return the camper to his/her home. I agree that, where the camp has taken all reasonable precautions and action, as it deems advisable, the camp administration, staff or sponsoring churches shall not be held responsible or liable for any accident, sickness, or misfortune to myself. In the event that the camper becomes ill or injured, I authorize the camp staff to administer any and all first aid measures. I authorize the Camp Directors to arrange and give consent for all necessary medical treatment or service to myself that shall be required in the best interest of myself.