2026 - 180 Weekend

Please Note: At the end of this form, you will be asked to fill out a 2026 Medical/Liability/Marketing Release form. This form is for REGISTRATION & PAYMENT for 180 Weekend 2026.

Student Info

Student Name

This address will receive a confirmation email

Address

Date of Birth

Gender

Other Info

Current Grade

School Name

Do you attend South Point Baptist?

If you do not attend South Point Baptist, what church do you attend? (If you do not attend church, put N/A)

Shirt Size (adult sizes)

Small Medium Large XL 2XL 3XL

Roommate Preference #1:

Roommate Preference #2:

Parent / Guardian Info

Please provide parent / guardian information. Single-parent households may put N/A for the secondary parent / guardian.

Primary Parent / Guardian: Name (First & Last)

Primary Parent / Guardian: Number

Primary Parent / Guardian: Email

Secondary Parent / Guardian: Name (First & Last)

Secondary Parent / Guardian: Number

Secondary Parent / Guardian: Email

Emergency Contact Info

In case of an emergency, we will contact one or both parents / guardians. If a parent / guardian is unavailable, please provide a secondary emergency contact below that we could reach out to.

IMPORTANT: DO NOT put your phone on "DO NOT DISTURB" while your student is away at this retreat.

Emergency Contact: Name (First & Last)

Emergency Contact: Phone Number

Emergency Contact: Relationship

Medical History

List or describe any known limitations/illnesses/conditions that our staff should be aware of in the event that medical treatment must be provided.

Physical limitations, Illnesses, or current medical diagnoses

Allergies and Dietary Restrictions

Are you Gluten-Free?

Yes No

Current medication(s) and reason for medication(s)

WAIVERS

We are excited to have your student attending our 180 weekend. Ahead of the weekend, we require that everyone fill out this 2026 Medical/Liability/Marketing Release Form.

CONFIRMATION of signing 2026 Medical/Liability/Marketing Release Form

COMPLETED

Payment

Payment Method

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2026 - 180 Weekend

Description

Please Fix the Following