Autumn Leaves Retreat 2012

Health/Release Form
October 26-27, Camp Fraser
101 Springvale Rd. Great Falls, VA 22066
Participants names:
1. _____________________________

4. _____________________________

allergies:______________________

allergies:______________________

_____________________________

_____________________________

Art Project

Art Project

Music

Games

(please select preference for Saturday morning)

Spending the night?

YES

Music

Spending the night?

Games
YES

NO

NO

5. _____________________________

2. _____________________________

allergies:______________________

allergies:______________________

_____________________________

_____________________________

Art Project

Art Project

Spending the night?

Music

Spending the night?

Games
YES

Music

Games
YES

NO

NO

6. _____________________________

3. _____________________________

allergies:______________________

allergies:______________________

_____________________________

_____________________________

Art Project

Art Project

Spending the night?

Music

Spending the night?

Games
YES

Music

Games
YES

NO

NO

Please list any other needs:

___________________________________________________________________________
___________________________________________________________________________
I, the undersigned, hereby agree to indemnify and hold harmless Calvary Baptist Church, its Board of
Trustees, its officers, employees and staff, from any liability as a result of either intentional acts or
negligence, or failure to act on the part of any of the above named entities or persons as a result of the
use of the premises while I am participating in any activities while at the Autumn Leaves Retreat at Camp
Fraser, October 26-27, 2012.
Signature: _________________________________________ Date: __________________
Emergency Contact: ________________________________________________________
Phone Number for Emergency Contact: _________________________________________
Brief Overnight Packing List
1. Closed-toed shoes

5. Bath towel

2. Clothes to play games in or to get

6. Bible, notebook (if desired)

messy during Art Project

3. Sleeping bag/sheets and pillow
4. Toiletries

7. Release form and $10 fee.

8. Your favorite board game!