2026 - Summer Mission: Kentucky (EARLY Registration)

June 22-27, 2026 | Registration for our 2026 Summer Mission to Kentucky. Open to Middle and High School Students.

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 Summer Mission to Kentucky.

Participant Info

Participant Name

This address will receive a confirmation email

Address

Date of Birth

Gender

Please select one option.

Male Female

Other Info

Current Grade

Please select one option.

6 7 8 9 10 11 12 Adult

School Name

Do you attend South Point Baptist?

Please select one option.

Yes No

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)

Please select one option.

Small Medium Large XL 2XL 3XL

Roommate Preference #1:

Roommate Preference #2:

Emergency Contact Info

In case of an emergency, we will contact one or both parents / guardians. Adults may put a spouse as emergency contact.

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?

Please select one option.

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

Please select one option.

COMPLETED

Payment

Payment Method

Deposit ONLY ($50) Full Amount ($150) Cash / Check ($0)

Amount

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

June 22-27, 2026

Registration for our 2026 Summer Mission to Kentucky. Open to Middle and High School Students.

2026 - Summer Mission: Kentucky (EARLY Registration)

Description

Please Fix the Following