EMBOLDEN 2022 Registration

Date: Friday, November 11 - Sunday, November 13
Time: 7pm Friday - 12pm Sunday (transportation times will be communicated by your Youth Minister)
Location: Camp Tecumseh in Pittstown, NJ
Who: All high school teens are welcome!
Cost: $175 (plus $25.00 late registration fee)

For questions, please contact Jean Stroud at jstroud@fiatventures.com

Payment Option:

Participant Information

*First Name

*Last Name

*Address

Apartment If Applicable

*City

*State

*Zip Code

*Email

*Home Phone (XXX-XXX-XXXX)

Cell Phone (XXX-XXX-XXXX)

*Gender

*Shirt Size

Parent/Guardian Information

First Name

Last Name

Home Phone (XXX-XXX-XXXX)

Cell Phone (XXX-XXX-XXXX)

*Allergies and any medication you will be taking during the event

Emergency Contact Information

*First and Last Name

*Relationship

*Home Phone (XXX-XXX-XXXX)

Cell Phone (XXX-XXX-XXXX)

Additional Information

Grade:

Parish:

Comments

Are you currently under the care of a physician, being treated for a chronic condition, or on prescribed medication? Do you have any food allergies or special food needs that we should be aware of?

Please hit button only once:

973.500.3300
P.O Box 4292, Warren, NJ 07059

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