Camp Shalom Retreat

Iowa City Retreat Registration!

Cost is $10
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
What time are you available to leave on Friday, October 26th *
Emergency Contact Name *

First Name Last Name
Relationship to You *
Emergency Contact Phone Number *

Area Code Phone Number
Allergies? *

Yes No
If Yes, Please Explain
Dietary Restrictions?
I personally assume responsibility for my actions, and release the Lutheran Student Center and locations of events from loss, injury or damage to myself or my property.I give permission to be photographed, recorded, and/or videotaped and to allow this material to be used for publicity purposes only. I give permission for the organizers to obtain medical assistance for me in the event of an emergency. *

Agree Disagree
Should be Empty:

Iowa City Retreat Registration!