10th Grade Confirmation Retreat

This weekend retreat will be an opportunity for the 10th graders who are preparing for confirmation to get away from their normal routine and encounter Christ in a powerful way. We will be partnering with In The Name worship to provide a retreat filled with praise and worship, the sacraments, small groups, and a ton of fun! Please be sure to register your 10th Grader before October 4th!

Dates: Friday, November 22nd - Sunday, November 24th

Drop off: Friday, November 22nd, 6:00 PM @ St. Vincent de Paul

Pick Up: Sunday, November 24th, 3:30 PM @ St. Vincent de Paul

Mode of Transportation: Bussing

Location: Trinity Woods Catholic Retreat Center

Cost: $200 (if you are in need of financial assistance please email: [email protected])

Student Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Sex REQUIRED Male Female Please fill out this field.

Birthdate (MM/DD/YYYY) REQUIRED Please fill out this field. Please enter valid data.

Parent/Guardian's Name (First and Last) REQUIRED Please fill out this field. Please enter valid data.

Home Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Parent/Guardian Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

Waivers

I, (Parent/Guardian Named Above) grant permission for my child, (Child Named Above), to participate in this parish/school event that requires transportation to a location away from the parish/school site. This activity will take place under the guidance and direction of parish/school employees and/or volunteers from St. Vincent de Paul Catholic Church and School.

I Agree Please select this field.

I understand and agree that as parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above-named minor (“participant”). I understand that my child is required to comply with the Code of Conduct provided by the parish/school while participating in the event. I understand and agree that if my child violates the Code of Conduct he/she may be required to be transported home at my expense.

I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold

harmless and defend St. Vincent de Paul Catholic Church and School, its officers, directors, employees and agents, and the Archdiocese of Saint Paul and Minneapolis, its employees and agents, chaperones, or representatives associated with the event and activities (hereinafter “Releasees”), from any claims, including but not limited to all claims relating to communicable disease, arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate Releasees for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of Releases.

I Agree Please select this field.

MEDICAL MATTERS: 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.

I Agree Please select this field.

(Of the following statements pertaining to medical matters, sign only those that are applicable.)

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:

Name and Relationship of Emergency Contact Please enter valid data.

Emergency Contact Phone Number Please enter valid data.

Family Doctor Please enter valid data.

Family Doctor Phone Number Please enter valid data.

Family Health Plan Carrier Please enter valid data.

Policy # Please enter valid data.

I agree Yes

Medications: My child is taking medication at present. My child will bring all such medications necessary and such medications will be well-labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage, are as follows:

*Check Yes only if child is taking medication and bringing.

I agree Yes

Names of any medications and directions for taking them Please enter valid data.

No medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life-threatening and emergency treatment is required.

*Check Yes only if child is NOT taking medication.

I agree Yes

I hereby grant permission for non-prescription medication (i.e. non-aspirin products such as acetaminophen or ibuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.

*Check Yes only if you grant permission for non-prescription medication to be given.

I agree Yes

Specific Medical Information: The parish/school will take reasonable care to see that the following information will be held in confidence.

Allergic reactions (medications, foods, plants, insects, etc.): Please enter valid data.

Immunizations: Date of last tetanus/diphtheria immunization: Please enter valid data.

Does child have a medically prescribed diet? Please enter valid data.

Does child have any physical limitations? Please enter valid data.

Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, bedwetting, fainting? Please enter valid data.

Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? Yes No

If yes, list date and disease or condition: Please enter valid data.

Does your child have any other special medical conditions we should be aware of? Please enter valid data.

As Parent or Guardian, I agree to all of the above stated considerations and conditions.

E-Signature REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED Please fill out this field. Please enter a date.

Payment

$200 Registration Fee REQUIRED $ Please fill out this field. Please enter a positive decimal.