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Who We Are
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Meet Reverend Cean R. James
Meet Rev. Christopher J. Holland II
Meet Rev. Sharell Shippen
Church History
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What We Believe
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Youth Retreat
Please Register for the youth retreat Below
Fill out the form below. If you need any assistance with this form, call the church at
215-883-0282
First Name
Middle Name(s)
Last Name
Gender
---Select---
Male
Female
Date of Birth
Age
School Name
Grade
Street Address
Town/City
State
Zip
Child's Home Phone
First Name
Last Name
Street Address
Town/City
State
Zip
Home Phone
Work Phone
Cell Phone
E-mail
Occupation
Employer
Emergency Contact 1
First Name
Last Name
Home Phone
Work Phone
Emergency Contact 2
First Name
Last Name
Home Phone
Work Phone
Insurance Info
Policy Number
Name of Health Insurance Provider
Primary Care Physician
Primary Care Address
Primary Care Phone
Hospital Preference
Please list any medical problems (i.e. Diabetic, Asthma, Seizures)
Should paramedics be called about any of these medical problems? (Please specify which)
Please list any allergies to food or medication
Please specify the details of any special diet your child requires.
I hereby give permission for my child to be photographed during the Youth retreat. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Salt and Light.
In the event of an emergency, I understand that Salt and Light (SNL) will try to contact me. If I am unable to be reached, SNL will do their best to ensure the safety and health of my child. I do not hold SNL liable in the event of an emergency.
By typing my name below, I am electronically signing this application.
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