24-Hour No Phone Retreat Registration Form
This form must be completed for EVERY youth attending. If your family has more than one child, you must fill this form out for every child. $10 retreat fee is per child and can be paid in-person or online here (please put "Retreat" in the notes": https://membership.faithdirect.net/givenow/IL909/30112

Retreat Contact Info:
RETREATS@ucym.org | 847-864-1185 x26
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RETREAT SCHEDULE
The retreat will be split into three parts. Please read carefully.

12-HOUR GATHERING:
SATURDAY, DECEMBER 14th
12 PM to 12 AM at St. Nicholas Parish

11-HOUR HOME FAST:
SUNDAY, DECEMBER 15TH
12 AM to 11 AM at HOME

CLOSING MASS
SUNDAY, DECEMBER 15TH
11 AM TEEN-LED MASS at St. Nicholas Parish
TEEN PARTICIPANT INFO
First & Last Name of Teen *
T-Shirt Size *
PARENT/GUARDIAN INFO
If you would like to add a second parent/guardian to this form, please contact us at RETREATS@ucym.org with "Name of Child - Retreat" in the subject line.
First & Last Name of Parent/Guardian *
Cell Phone # of Parent/Guardian *
E-mail Address of Parent/Guardian *
EMERGENCY CONTACT
The emergency contact CANNOT be the parent/guardian listed above. In the event a child is hurt and needs to be taken to the hospital and the parent/guardian above cannot be reached, the emergency contact is the next person responsible or to be called.
Emergency Contact First & Last Name *
Emergency Contact Relation to Teen Participant *
Emergency Contact Phone # *
PERMISSIONS
Please note that your electronic signature and by clicking "Yes" to the questions below is your permission on behalf of any teen under the age of 18.
COMMUNICATION: [IMPORTANT, PLEASE READ CAREFULLY]: I hereby give James Holzhauer-Chuckas, ObSB (Regional Director of Youth Ministry) and other any Archdiocesan child protection-compliant adult volunteer on the Youth Ministry Team permission to communicate with my teenager through text message and other online communications tools: GroupMe, Facebook, Twitter, Instagram, and Email to discuss meetings, formation, and other matters pertaining strictly to Youth Ministry. I acknowledge and agree that if I have any concerns regarding questionable activity that I will contact the undersigned staff members and that they may involve the Pastor. *
MEDICAL AUTHORIZATIONS: In the event that the undersigned cannot be reached, and in the judgment of the responsible adults or other appropriate staff members accompanying the group, if 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 GRANT PERMISSION for the Youth Ministry personnel to administer non-prescription drugs as advised by the Youth Director as needed for my teen (aspirin, ibuprofen, etc.) *
PHOTO RELEASE: I AUTHORIZE the Parishes of the Evanston & Skokie Archdiocesan Grouping to use photographs/videos of my child strictly for church-related productions, publications, etc. *
LIABILITY WAIVER: I hereby give permission for my teen to participate in the Evanston Soccer Festival on behalf of United Catholic Youth Ministries of Evanston & Skokie. I hereby release and indemnify the Archdiocese of Chicago, St. Nicholas Church for this event, its staff and 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 the program. I understand that if my child violates any laws regarding possession of alcohol or drugs, or rules governing the program, I will be called and notified about the situation and/or arrangements made to send my child home at my expense during any event. Please write FULL NAME AND RELATION TO TEEN of adult signing for teen participant as an electronic signature. *
Thank You!
If you have any questions, please do not hesitate to reach out!
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