St. Michael Catholic Church · February 15-17, 2019 High School Retreat Registration

February High School Retreat Enrollment

2019 Spring Awaken High School Retreat

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Click next to the date to register for the 2019 Spring Awaken Retreat

Fri. February 15, 2019 4:00pm – Sun. February 17, 2018 1pm $200 (New Ulm, TX)//Meet at St. Michael at 4:00 pm. We will be departing via Bus on Friday November 2nd. We will returning via bus to St. Michael by 1:00 pm on Sunday November 4th.

Teen Registration Information

Teen Full Name

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First Name

Last Name

Teen Preferred Name

First Name

Last Name

Teen Gender

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Female

Male

Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Teen Date of Birth

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(mm/dd/yyyy)

Teen Email

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Teen Cell

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Can the Youth Ministry team can communicate with your teen via text messaging?

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Yes

No

High School Attending

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Grade 2018-2019

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T-Shirt Size

Parent/Legal Guardian Information

Parent/Legal Guardian #1

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First Name

Last Name

Relationship to Teen

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Primary Email

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Confirm Primary Email

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Primary Contact Phone Number

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Is this a number that you can text from?

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Yes

No

Parent/Legal Guardian #2

First Name

Last Name

Relationship to Teen

Primary Email

Primary Contact Phone Number

Is this a number that you can text from?

Yes

No

Teen primarily lives with: (Check all that apply)

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Father

Mother

Stepfather

Stepmother

Grandparents

Other

Local Emergency Contact (Other than parent/guardian)

Contact's Full Name

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First Name

Last Name

Relationship to Teen

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Primary Contact Phone Number

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Teen Medical Information

THIS INFORMATION WILL BE KEPT CONFIDENTIAL. Please provide the medical information below. It will be kept in your teen's records for use by Youth Faith Formation in case of a necessary medical situation.

Doctor's Name

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Doctor's Phone Number

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Insurance Company

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Insurance Phone Number

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Policy/Group/ID number

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My teen is currently taking the following medications:

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Please specify prescription and over the counter medications, dosage and frequency.

Allergies/Health Concerns

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Special Needs

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learning and/or physical needs and/or medical conditions

Over the counter medications

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Please select one

I GIVE permission to administer over the counter medication to my teen as needed.

I DO NOT GIVE permission to administer over the counter medication to my teen.

My teen has allergic reactions to the following:

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ex. foods, dyes, latex, medications, or put Not Available (N/A)

My teen has had a medical surgery within the last six months:

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Please describe or put Not Available (N/A)

My teen has a medically prescribed diet:

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Please describe or put Not Available (N/A)

My teen has the following physical limitations:

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Please describe or put Not Available (N/A)

My teen had their last tetanus/diphtheria immunization around:

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approximate month and year

Video and Photography Consent

As parent/guardian, I understand that promotional pictures and videos (individual and group) will be taken during this event. I give permission for my son’s/daughter’s picture to be used for promotional materials (newsletter, web page, calendars, power point, video etc.) in highlighting the event.

Please choose one

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Yes, I give permission

No, I do not give permission

Consent and Liability Waiver

I grant permission for my child to participate in St. Michael Youth Faith Formation to be held February 15-17,2019. In consideration of my son’s/daughter’s participation in this event, I agree on behalf of myself, my child named herein, and our heirs, successors, and assigns to indemnify, hold harmless and defend the Archdiocese of Galveston-Houston, the sponsoring parish, its pastor, youth ministry leader, principal, other agents, employees or other representatives associated with the event from any and all injuries, losses or claims arising out of my child’s participation in the event.

In signing this form I certify that all information contained herein is true and accurate to the best of my knowledge.

Full Name of Parent/Guardian if student is under 18 years of age or full name of student if student is 18 years of age

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Full Name of Student Registrant

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Parent Volunteers For Retreat

Would you like to help us out this year?

Please check as many as desired

Small Group Leader on Retreat

Providing Snacks and bottled water for Retreat

Help sign in teens as they arrive at St. Michael at 4:00 pm on Friday November 2nd.

Prayer Team (Does not attend retreat with us, but prays for the teens and leaders while they are on retreat.)

Payment Information

Fees for one retreat February 15-17, 2019

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$0- we are using this as our Confirmation retreat (One retreat was included with your Confirmation prep. Registration.)

$205 -Full Cost for 1 retreat- Includes Includes transportation, lodging, activities, and 5 meals for Feb 15-17 Retreat

$51.25-Quarterly payment plan Includes transportation, lodging, activities, and 5 meals for Feb 15-17 Spring Retreat

$17.08- Monthly payment plan Includes transportation, lodging, activities, and 5 meals for Feb 15-17 Spring Retreat

$0- We are unable to pay at this time, and would like a parishioner to sponsor us for the retreat.Includes transportation, lodging, activities, and 5 meals for Feb 15-17,2019 Spring Retreat

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