Program Registration Form
P.O. Box 10606 * Jackson, TN 38308-0110
731-438-9018 * 6qdz8dgjtw@snkmail.com

Name of Participant : ____________________________________________ [ ] Handicap Assistance

Address/P.O. Box : ___________________________________________________________

City :  ___________________ State : _________________ Zip : _______________________

Home Phone : (_______)_________________ Other Contact Number : (_______)____________________

E-Mail Address For Updates and Conformation : ________________________________________________________

Room Status? ( mark all that apply )
(  ) Joining Room (  ) Family Member (  ) Non-Share Room (  ) Share Room (  ) Share Room  ( Others )
(  ) Husband/Wife ( Non-Share ) (  ) Group Member ( must be in groups of 4 to share same room )

  • Participant is responsible for their transportation
  • The Registration Fee includes Three Night Room Stay and Three Evening Meals, Per Person
  • Send the Non-Refundable Deposit of $200.00 Per Four Participant Registration 
  • We accept Cashier/Certified Check or Money Order payable to Jeffery G Douglas and Major Credit Cards By Internet and the Balance is Due 30 Days by mail or 15 days by Credit Card Before Departure, no refunds can be made.
  • Upon receipt of full payment, you will receive your Conformation Number and additional information
  • Please consider making a Tax-Deductible donation to our Area Help Center - Regional Inter-Faith Association ( RIFA ). Your generosity will allow RIFA to serve those who are victims of  fire, abuse, homelessness, etc..  

    • I'd like to donate $_____________ to RIFA Center and have enclosed a check payable to :
    Regional Inter-Faith Association

    Please sign form below. When paying by Credit Card, you will receive a e-mail with payment link to make the non-refundable deposit and will receive another e-mail notice 15 days before departure. When Paying by mail balance due 30 days before departure. No Participant under 18 without their Parent or Guardian's Signature and Adult Supervision.

    ______________________________________________                                         _____________
    Signature Of Participant                                                                                                      Date

    ______________________________________________                                         _____________
    Signature Of Parent or Guardian Of Minor                                                                         Date

    ______________________________________________                                          _____________
    Signature Of Adult Attending of Minor ( if Not P/G )                                                        Date

    FULL PAYMENT AND ALL FORMS REQUIRED BEFORE ATTENDANCE.
    FORMS WILL NOT TAKEN AT DOOR

     

    Program Confidential Questionnaire Form
    P.O. Box 10606 * Jackson, TN 38308-0110
    731-438-9018 * 6qdz8dgjtw@snkmail.com

    Name of Participant : ___________________________________________

    Age : __________  Date Of Birth: ______/______/________ Sex:________

    Circle all of the following that applies and please explain below if you have any previous injuries, pre-existing conditions, special conditions/needs, or other pertinent medical information ( such as recent surgery )

    Eyes,    Ears,    Lungs,    Lower Back,     Thighs,    Arm,    Head,     Asthma,    Groin,    Ankles     

    Neck,    Heart,    Pelvis,    Feet,     Smoke,    Tobacco,    Hands,    Wrists,     Internal Organs,    Legs

    Knees,    Diabetes,    Blood Pressure,     Upper Back,    Shoulders,    Wear Contacts,    OTHER   

    PLEASE EXPLAIN ANY ANSWERS HERE:
    _______________________________________________________________________________________
    _______________________________________________________________________________________
    _______________________________________________________________________________________
    _______________________________________________________________________________________
    _______________________________________________________________________________________
    _______________________________________________________________________________________

    ALLERGIES; ( Food, Medicine, Bee Stings, ect,)
    _______________________________________________________________________________________
    _______________________________________________________________________________________
    _______________________________________________________________________________________
    _______________________________________________________________________________________
    _______________________________________________________________________________________
    _______________________________________________________________________________________
    _______________________________________________________________________________________

    IF YOU ARE CURRENTLY UNDER THE CARE OF A PHYSICIAN or PSYCHOTHERAPIST YOU MUST OBTAIN "A TRAVEL RELEASE" STATEMENT LETTER FROM THE PHYSICIAN or PSYCHOTHERAPIST

    I have read the above questions and certify that to the best of my knowledge my answers are complete and true and I'm The Participant, the Parent or Guardian of Participant under 18 years of age.

    SIGNED :_____________________________________ DATE: ______________________

    Complete a registration for Each Person,
    Send Forms and Deposit to
    "Program Registration"
    P.O. Box 10606
    Jackson, TN 38308-0110