Connect High School Retreat Sign Up (Nov 5, 2022)

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Thank you for signing up for the Connect High School Retreat Sign Up (Nov 5, 2022) which will take place at Holy Family Parish from 12:30pm to 9pm. If you have any questions or problems signing up, please contact Brendan Slovacek at (815) 355-6815 or connectsteubenville@gmail.com.

Participant’s FIRST Name: *

Participant’s LAST Name:
*

Participant’s Birth Date:
*

YYYY

Sex: *

Male

Female

Parent/Guardian’s Name:
*

Parent/Guardian’s Phone Number:
*

Home Street Address; City; State:
*

Parish Name *

Emergency Contact NAME for Nov. 5 *

Emergency Contact PHONE Number *

Family Doctor:

Family Health Plan Carrier:

Policy #:

Policy Holder Name:

I hereby grant permission for non-prescription medication (such as aspirin, throat lozenges, cough syrup) to be given to my child, if deemed appropriate. (check and complete only those that apply):
*

Yes

Required

Allergic reactions (medications, foods, plants, insects, etc):

Date of last tetanus/diphtheria immunization:

YYYY

Does the participant have a medically prescribed diet?

Any physical limitations?

Is the participant subject to chronic homesickness, emotional reactions to new situations, sleepwalking, bedwetting, fainting, etc.?

Yes

Clear selection

Has the participant recently been exposed to contagious disease/condition, such as mumps, measles, chickenpox, etc.? If so, date and disease/condition.

You should be aware of these special medical conditions of my child:

Parents/Guardians: Write Name as An Electronic Signature *

Write Today's Date: *

YYYY

There is a suggested $10 donation for each student. This can be turned in via cash or check (made payable to Holy Family Parish) at the sign in table on any Wednesday night Connect meeting or the day of the retreat. No student will be turned away due to the cost. *

I acknowledge the above statement.

Required

Submit

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