Kairos 40 Registration

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Kairos 40, hosted by St. Francis Xavier

St. Mary's Retreat House, Lemont, IL

Dates: February 23rd - February 26th

Retreat Fee: $300 (if cost is the only thing prohibiting you from joining us, please email us about scholarship information).

Teen First Name: *

Teen Last Name: *

Nickname:

Date of Birth: *

YYYY

School: *

Year in School: *

Junior

Senior

Church/Faith Community: *

St. Francis Xavier

St. John of the Cross

St. Cletus

Other:

T-shirt Size *

XXL

Address with City, State, and Zip *

Teen Phone Number: *

Teen Email: *

Parent/Guardian 1 - First and Last Name: *

Parent/Guardian 1 - phone number:
*

Parent/Guardian 1 - email
*

Parent/Guardian 2 - First and Last Name:

Parent/Guardian 2 - phone number:

Parent/Guardian 2 - email:

Guidlines and Expectations (to be completed by teen) Check all guidelines to signify that you meet the guidelines and will adhere to the expectations: *

I am a junior or senior in high school

I will participate in all group activities

I will respect the property we will be using, as well as the property of others

I will not leave the facility during the retreat

I will not bring illegal substances or electronic devices (phones, laptops, devices, games)

Alcoholic beverages/drugs of any kind.sex are not allowed and will not be tolerated

I understand that I will have a roommate during the retreat

By checking this particular box I confirm agreement with the preceding terms.

Required

How did you hear about Kairos?

Please briefly explain why you want to attend this Kairos retreat? *

ParentGuardian Affidavit and Authorization: I give permission for my teen to attend the Kairos retreat sponsored by St. Francis Xavier Parish, during the dates of February 23 to February 26, 2023. I am aware that my teen will travel by bus and stay at St. Mary's Retreat House in Lemont, IL.
I hereby release and indemnify St. Mary's Retreat House, its staff, the staff and volunteers of St. Francis Xavier Parish, a corporation sole, from any and all liability arising from claims of any kind or nature whatsoever from my child's participation in the program. In the event that I, my spouse, or our authorized physician cannot be reached, and in the judgement of the adult leaders there is a necessity for immediate examination and/or treatment of my child, I hereby authorize any of the aforesaid personnel to obtain for my child such medical services as are deemed necessary.
I understand that I will be called and asked to pick up my child immediately if he/she does not abide by the rules of the weekend as stated above. (Name and Date in box below counts as your signature) *

Physician Name AND Phone Number: *

Medical Insurance Company AND Policy Number: *

Please list all of your child's medical conditions, medications, or dietary needs: *

Payment must be made through St. Francis Xavier Parish's Give Central. Link provided below.

https://www.givecentral.org/location/218/event/11410

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