Disneyland
Retreat 2023

Please fill out the form below to get your teen(s) registered for our Disneyland Retreat from June 13th through June 15th. We’ll be arriving back in San Diego (Church Parking Lot) on the night of the 15th.

There are only 13 total spots available, so register as soon as possible! Priority registration will be given to actively participating youth.

Payment info and a full registration form will be sent out as soon as your spot is confirmed.

Youth Name

First Name

Last Name

Youth's Gender Identity

Youth's Age & Grade

Youth's Cell Number

(###)

###

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Parent 1

First Name

Last Name

Parent 1 Cell Phone

(###)

###

####

Parent 1 Email

Parent 2

First Name

Last Name

Parent 2 Phone

(###)

###

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Parent 2 Email

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

First Name

Last Name

Relationship to Youth

Emergency Contact Cell Phone

(###)

###

####

Insurance Carrier/Plan Name

Group Number

Name of Policy Holder

Policy Number

Physician Name

First Name

Last Name

Physician Phone

(###)

###

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Does your teen have allergies?

No Allergies

My teen has allergies

Medication Allergy

Food Allergy

Other Allergy

Plant, Animal, etc.

If Teen is on medications, what are they & what is the dosage?

Any Health Concerns?

Asthma, Headaches/Migraines, Motion Sickness, etc.

DisneylandRetreat 2023

Disneyland
Retreat 2023