PARTICIPANT- Nov. 5-6, 2022 Reflections Confirmation Retreat Registration

DATE: Saturday, Nov. 5 -Sunday, Nov. 6
Please arrive at 1:00 p.m.
Parents should plan to pick-up at 5:30 p.m.

LOCATION: Bradford Woods

COST: $85
Please register online and turn in a check (written to St. Susanna) or cash to the Faith Formation Office
**If you would like to pay by credit card for the retreat, there will be a $3 fee, and you should contact Ellice Bedel by e-mail to find out how to pay online with your card.

Name Name First Last
T-Shirt Size (cost included in registration)
Parent Email
Home Phone Home Phone - ### - ### ####
#1 Parent Name #1 Parent Name First Last
#1 Parent Cell Phone #1 Parent Cell Phone - ### - ### ####
#2 Parent Name #2 Parent Name First Last
#2 Parent Cell Phone #2 Parent Cell Phone - ### - ### ####
Grade
Gender
High School
Emergency Contact Name (other than parents)

Emergency Contact Name (other than parents)

First Last
Emergency Contact Relationship
Emergency Contact Phone # Emergency Contact Phone # - ### - ### ####
Allergies, Medical Condition, Dietary Needs, or any other Special Needs:
**Put 'NA' if it is Non-Applicable
Medication: If medications (prescription and non-prescription) are needed, please send them with your child. List these medications in the following section and include product name and physician's instructions on dosage and frequency. Any medicine brought to retreat should be clearly labeled in their original container and check in at registration.
**Put 'NA' if this is Non-Applicable
Family Doctor
Doctor Phone # Doctor Phone # - ### - ### ####
Health Plan Carrier
Policy Number
LIABILITY WAIVER
Please sign below to indicate you have read and agree to the terms of the following Liability Waiver:

I grant my son/daughter permission to participate in the REFLECTIONS Confirmation Retreat on November 5-6, 2022.

In consideration of the opportunity for my child to participate and fully recognizing that such an undertaking involves an element of risk, we assume all risks and hazards incidental in such participation and do hereby release, absolve, indemnify, and agree to hold harmless St. Susanna Parish, the Archdiocese of Indianapolis, its agents, employees and offices and the chaperones, leaders, organizers and sponsors, and persons. Neither the Archdiocese of Indianapolis/St. Susanna Parish nor any of said persons shall be held financially responsible for any injury, illness, or death incurred as a direct or indirect result of the activity. I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.

In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical treatment to be administered. I wish to be advised prior to any further treatment by the hospital or doctor.
We, the undersigned, have read this release and understand all its terms and execute it voluntarily and with full knowledge of the significance.
**Parent, draw your signature into the box below:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
CODE OF CONDUCT- Student Portion:
I am willing and committed to follow all expected guidelines and rules for safety and consideration of others during the entire time that I am present on the confirmation Retreat. (THIS includes but is not limited to: going to bed at appointed time, no drugs or alcohol, proper attire and following directions of chaperones and leaders. I understand that my parent/guardian will be notified immediately of any infractions and that I will be sent home at the inconvenience of my parents if necessary.
**Student, draw your signature into the box below:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
CODE OF CONDUCT- Parent Portion:
I grant permission for my child to participate in The St. Susanna REFLECTIONS Confirmation Retreat. I agree that my child will abide by all the rules and guidelines. I understand that participation in this retreat includes me providing my teen transportation to and from Bradford Woods. I understand that if my son/daughter does not follow guidelines of this retreat he/she may be sent home at the discretion of the Coordinator of Youth Ministry, Ellice Bedel, and I must be available to pick him/her up.
**Parent, please draw your signature into the box below:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.