Registration Form


Age: 14(born 2005) and up to young adults
EARLY BIRD (deadline is april 30): $75
Forms can be submitted via mobile app or mailed to Victoria Zurawski, 979 Notre Dame dr. London Ont. N6J 3C3
or emailed to
or send through messenger to Victoria Zurawski

REGISTRATION: Friday, May 24 2019, 6-8pm RETREAT ENDS: Sunday, May 26 2019, 3pm.
Things to bring: health card, bible, sleeping bag, pillow, toiletries, towel, weather appropriate clothing and light jacket

First Name

Last Name



City and Postal Code

Phone Number


Date Of Birth

Health Card #

Medical conditions we should know of?

If yes please explain

Email Address

Emergency Contact and Relationship

phone #1

phone #2

What church do you attend?

Any questions?