Leaders Retreat Registration Blueprint Conference Registration Step 1 of 3 33% Leader InformationWhat church do you attend?(Required) Church Name Leader's Name(Required) First Last Leader's Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Leader's Birth Date(Required) MM slash DD slash YYYY T-Shirt Size(Required) Small Medium Large XL 2XL 3XL 4XL Other Gender(Required) Male Female Leader's Email(Required) Leader's Cell Phone(Required)Who will be attending with you? How many people? Food AllergiesDoes Leader have any food allergies?(Required) Yes No Please list food allergies below:(Required) Liability Release & SignaturesSummit Camps Liability Release Agreement(Required)I will not hold the attending Church, Summit Camps, Kiamichi Baptist Association, Green Country Camp (Green Country Baptist Assembly) responsible for any accident that may occur. I also give permission to receive medical treatment or attention in case of emergency or illness while traveling and/or while under the supervision of above referenced Church, sponsors, and/or camp staff. I expressly understand and acknowledge that during the course of the camp photographs and/or video footage may be taken and I hereby give permission for such photographs or videos to be used on the camp website and/or for promotional materials for the camp. I agree to the Summit Camps liability release.
