FLAME I Retreat Registration Form

I/We, the parent(s) of
Name
First Last
request that Holy Family Teen Faith program allow my/our child to participate in

Event: FLAME I Retreat
When: 8:00am Saturday, February 29, 2020 – 11:30am Sunday, March 1, 2020
Place: Loyola University Retreat & Ecology Center, Woodstock, IL

I hereby release and indemnify Holy Family Parish, its staff and its volunteers and the Catholic Bishop of Chicago, a corporation sole, from any and all liability arising from claims of any kind or nature whatsoever from my child’s participation in this event.

In the event that the undersigned or my (our) authorized physician, cannot be reached, and in the judgment of a responsible person accompanying the group, or other appropriate staff member, there is a necessity for immediate examination and/or treatment of my (our) child, I/We hereby authorize any of the aforesaid people to obtain for my child such medical services as are deemed necessary.
Home Phone Number
Other number (if applicable)
Family Physician
Phone Number
Name of Insurance Co.
Insurance Phone
Person to contact in case of emergency (if unable to reach parent):
Emergency Contact Name/Relationship
Emergency Contact Phone
Parent(s) Name(s)
First Last
Specific medical allergies, chronic illnesses and other conditions. Please list any & all medications that your child may take during the retreat.
Please list a roommate request. We do our best to accommodate requests if possible.
Roomate Request 1
Roomate Request 2
- Check here if you would be willing to assist at sign in the morning of the retreat (7:45-8:30am)
- Check here if you are available to assist in the Teen Faith office with retreat prep the week before the retreat
Parent/Guardian Signature
Date
MM slash DD slash YYYY
I understand that by signing my teen up for this retreat, he/she will attend the retreat in its entirety, from 8am on Saturday until 11 :30 am on Sunday. I acknowledge that there is no coming late and no leaving early. parent
Parent Initials*
Comments
This field is for validation purposes and should be left unchanged.