Participant Information

First Name
Last Name
Middle Initial
E-Mail
Address
City
State
Zip-Code
Phone
Date of Birth
Age	18 19 20 21 22 other
Sex	Male Female

May we share your information with the other TEC participants
so that everyone may keep in touch ?
Yes No

Medical Information

Primary Care Provider
Insurance Provider
Group ID
Policy Number

Religious Information

Church attended, if applicable
Baptised ?	Yes No
Pastor
Phone

Parental / Guardian Information (if applicable)

Name of Parent / Guardian

Full Name
Phone
E-Mail

Something about yourself...

How did you hear about TEC ?
Describe your participation at school
Describe you special interest & hobbies
What are you looking for in your TEC experience ?
Have you been to other youth retreats and/or conferences?

If you are placed on a waiting list, would you be able to come on short notice ?
Yes No

The cost of attending our TEC weekend is $85.  Please make your check out to the Diocese of Savannah and reference "TEC Retreat" in the memo field.  Savannah TEC is not a "For Profit" organization and these cost are to cover the expenses of the facilities, meals and other costs related to the retreat.

Please mail checks to:

TEC Treasurer
4329 Sun Valley Place,
Martinez, Ga. 30907

FEE SUBSIDIES

Savannah TEC has established the means for a case by case instance of subsidies for people who simply are unable to pay all or part of the cost of attending TEC. Would you like to be contacted regarding financial assistance ?
Yes No

We would like to remind you that non-prescription drugs, alcohol and any other form of unwanted behavior is not permitted on the weekend.

Medical and Permission Form
Please print and fill out this form and mail it to:

TEC - Chair
c/o Diocese of Savannah
4329 Sun Valley Place
Martinez, Ga. 30907