DSC Rebel Retreat Registration Form

Cost: 

$40.00.  Register three weeks prior to reserve a T-shirt.  Food will be provided.

Payment methods: 

• Mail check or money, payable to DSC School Relations.  Address - DSC Admissions, 225 S 700 E, St. George, UT  84770
• Pay with credit card (Visa, MC, Discover) by calling DSC Cashier's Office - (435) 652-7605.   (sorry, no refunds)

First Name:     Last Name:     Phone: 

Street:     City:    State:     Zip: 

T-shirt Size:  Small Medium Large X Large    Have you applied for admission?  Yes No

I (or my legal guardian) assume all responsibility for any harm that may occur during participation in DSC's Rebel Retreat.  I am personally responsible for my own safety in getting to and from the Rebel Retreat.  Dixie State College accepts no liability for any harm that could occur traveling to and from the activities associated with the Rebel Retreat.  I (or my legal guardian) release DSC from all liability, negligence, or breach of warranty associated with injury, loss, claim, damage, or harm that may occur.  Consent is expressly given for any emergency medical aid to be administered at the recommendation of the attending physician.  I understand and agree to the contents of this waiver pertaining to participation in the Dixie State College Rebel Retreat.  If the participant is a minor, a legal guardian must read the aforementioned disclaimer and check the box indicated.

I have read the above and agree to comply with the provisions indicated:  Yes No      Guardian Name:     Guardian approval (if applicable):  Yes No

Please click the submit button when complete: