Christmas Institute 2011 Call of Duty: Spiritual Warfare

Dec. 26-30, 2011 Loucon Training & Retreat Center 8044 Anneta Road, Leitchfield, KY 42754

Registration Form
Church: Youth Leader/Pastor: First Name: Address: City: Phone: Birth Date: Last Name: State: Country: Email Address: Age as of 12/26/11: Preferred Name: Sex: M F Zip Code:

Role (please mark with X): Youth Participant (K-grade 5) Youth Participant (grades 6-8) Youth Participant (high school) Guest Speaker Reason for attending CI 2011:

Youth Participant (college) Youth Participant (23-30 years old) Adult Chaperone

Medical/Special Needs Medical Condition; Current medication; Allergies that need special attention:

Special Dietary Needs:

Emergency Contact Name: Phone:

Relation:

*Please make checks payable to St. Johns Youth with memo CI 2011. Registration is incomplete until payment has been received.