Confirmation Retreat 2019

Confirmation

Required Confirmation Retreat 2019

The form below registers the youth(s) for the Confirmation Retreat.

Parent or Guardian Contact Information
Name
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Address
Phone --
E-mail
Individual Child Registration
Child #1
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Birthday //
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Known Allergies, medical or physical conditions of child:
  •  
If none, just type "NONE"
Medication for child
  •  
Please write "None or NA" if none are taken.
Child #2
  •  
Birthday //
  •  
Medication for child
  •  
Please write "None or NA" if none are taken.
Known Allergies, medical or physical conditions of child:
  •  
If none, just type "None"
Child #3
  •  
Birthday //
  •  
Medication for child
  •  
Please write "None or NA" if none are taken.
Known Allergies, medical or physical conditions of child:
  •  
If none, just type "None"
Medical Information
Medical Insurance Provider
Insurance Policy #
Doctor
  •  
Doctor's Phone Number --
Emergency Contact
  •  
Emergency Contact Phone # --
Emergency Contact's relationship to child(ren)
Permission Slip My child(ren)/ward(s), has my permission to attend the Confirmation Retreat. The student understands that he/she DOES NOT have permission to drive. I understand that neither St. Monica's Church nor its employees and volunteers are liable for any injury sustained by my child while he/she is on St. Monica's Property. I agree to release and hold harmless St. Monica Church and its agents from any and against any and all liability, loss, damages, claims, or actions for bodily injury, and/or property damage, in accordance with current state and federal law, arising out of participation in this trip. I, the undersigned parent or guardian of the minor child/ward, do hereby authorize the adult leaders, teachers, administrators, or other proper agents of the St. Monica Church to act as agent for the under-signed to consent to any X-Ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care for the above minor child which is deemed advisable and to be rendered under the general or special supervision of any physician or surgeon, licensed under the provision of the Medicine-Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, camp, or elsewhere. I agree to be responsible for the cost of such treatment.
***
Legally binding e-signature
Event and Cost
Retreat Payment  
Quantity Extended

Confirmation Retreat | $25.00

Retreat Price

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Order Summary
Subtotal
Discount
Sales Tax
Shipping & Handling
Total

Payment Type


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