D-Now Youth Retreat (2026)

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Student Name

*

Student gender

*

Student grade

*

Student allergies/dietary restrictions/medical disclosures

*

Parent Name

*

Parent Email

*

This address will receive a confirmation email

Parent Phone

*

Emergency Contact Name

*

Emergency Contact Relationship to Student

*

Emergency Contact Phone

*

Address

*

T Shirt Size

*

Please select one option.

S M L XL XXL Other

Church ("none" if none)

*

I understand that middle schoolers must be picked up at 9:00pm on Friday. High school students will stay overnight at Eastside Baptist Church (Springfield)

*

Please select one option.

Yes, I understand I have questions

Other notes or comments (optional)

Payment

Regular Registration ($25.00) Paying cash later ($0.00)

Amount

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

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