Extreme Equipping Retreat Application

Fill out all fields of the form below and click the submit button when finished.

Photo Consent Form
If registering by mail, send the consent form along with enrollment form and your check to: eXtreme Youth Community International: PO Box 54067 Omaha, Ne. 68154. If not paying by mail, please bring Photo Consent form to your first retreat.

Student Information
How Many Brothers and Sisters Do you have?
Tell Us More About Yourself
Do you know Jesus as your Lord and Savior?
Write a short paragraph about who Jesus is to You. (Feel free to express your true feelings if you don't really know Him yet).
Parent Information
Emergency Contacts
Please read all the statements below before submitting.

Read Before Submitting!


As a parent or guardian I understand that reasonable precautions will be taken when working with my child, but in spite of this, accidents can happen and illnesses may develop; therefore, I will not hold eXtreme Youth Community International Corporation, its board members, leaders, teachers, volunteers, or any other staff, individually or corporately liable for any illness or accident resulting from the above named child's/children's participation at any eXtreme Youth Community International event, retreats, conference, etc. In case of emergency, I hereby give permission to the leaders and workers to contact appropriate medical help and provide care as they view suitable. Furthermore, as a parent or guardian I also understand that it is the desire of eXtreme Youth Community to meet the spiritual needs of all who attend events including attendance at any equipping retreats.
However, if my child's behavior or attitudes do not further the goals of the ministry (which is to equip and train a generation to be fully functioning members of the Body of Christ), I understand that eXtreme Youth Community reserves the right to remove my child from retreats, outreaches or events at any time.

We will do what we can to love and support each child and family who attends any or all of our events.

Scott and Diane Cory
Directors of Extreme Youth Community

Registration Fee Information

You may pay $20.00 at the door, at the start of each Friday night retreat.  

There will be a $30.00 charge at the door for our February 18th retreat with Mike Seth and Lenny LaGuardia unless you have paid for all 10 sessions in advance.

or bundle your sessions and "Pay" in advance on-line (Paypal or by mail-see pay options)

Fees - $200.00 for all 10 sessions.
If you are enrolling more than one child and you pay in advance, the discount for siblings is as follows:

First child = $200.00
Second child = $190.00
Third child  = $180.00
Fourth child = Free
Etc.
 

The fee is non-refundable. It is non-refundable at any time during the course if the child is removed for disciplinary reasons.