Student Name *

First Name

Last Name

Student Cell Phone

(###)

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Student Date of Birth *

MM

DD

YYYY

Parent(s) Name *

First Name

Last Name

Parent 1 Cell *

(###)

###

####

Parent 2 Cell

(###)

###

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I understand that the price of the fall retreat is $85. *

2 kids in same family = $85 and $80 3 or more kids in same family = $85, $80, and $75

Yes

I understand my student's spot is not saved until payment is received. *

Space is LIMITED as camp is FULL. We will start a waiting list if needed when we run out of beds.

Yes

Payment Deadline October 31, 2025 *

I will pay via:

Online

Cash or Check in offering box with RSM Camp in memo

I understand I need to complete the 2 forms below for each of my students.

Yes

Name *

First Name

Last Name