Fall Retreat Registration Form 2022

Fall Retreat Registration Form

We are so excited that you are joining us for Fall Retreat! It will take place November 4-6, 2022 at Redemption Ranch in Winfield, MO. Please fill out the registration form below.
Participant Full Name *

First Name Last Name
Participant Phone Number *
Participant E-mail *
example@example.com
Gender *
Grade *
T Shirt Size *
Parish? *

Emergency Contact
Parent Name *

First Name Last Name
Parent Email *
example@example.com
Parent Phone Number *
Parent Name

First Name Last Name
Parent Phone Number
Any special dietary requirements, medical history, medication or major allergies? *

Medical
Physician *
Phone: *
Health Insurance Company *
Policy #: *
I grant permission to adult chaperones to give my child non-prescription drugs (Tylenol, etc.) in the event circumstances reasonably demonstrate that my child is in need of such drugs.

I hereby authorize any adult chaperone to consent to any medical treatment of the named youth, which, in the judgment of a recognized medical facility, under the general or special supervision of a licensed physician, may be deemed necessary.
Parent Signature *

Clear

Transportation Permissions

We will meet at Assumption on November 4th to carpool to Redemption Ranch. It is about a one hour drive. We will return to Assumption on November 6th mid-morning.
Please check all that apply.

I give my teen permission to drive themselves to Fall Retreat. I give my teen permission to drive themselves to Fall Retreat and to have other teen passengers in the car. I give my teen permission to ride in the car of another teen driver. I give my teen permission to ride in the car of an adult driver. I would be willing to be a parent driver, and drive a few teens TO Fall Retreat, if we need more drivers. (November 4th around 5pm) I would be willing to be a parent driver, and drive a few teens FROM Fall Retreat, if we need more drivers. (November 6th around 10:00am)

I hereby authorize my son/daughter to attend Fall Retreat. I understand that Fall Retreat participation requires a commitment to the full weekend experience and leaving for other activities is prohibited.

I understand that my son/daughter will be offered the opportunity to participate in various activities throughout the weekend. It is understood that all possible caution will be taken by those persons in charge to keep everyone safe and to prevent injuries, but neither chaperones, young adult leaders, teens, employees, nor Assumption Parish will be held responsible in the case of an accident or injury.

I understand that for all Youth Ministry activities there is a zero tolerance policy for the use of any mood altering chemicals (including alcohol and illegal drugs), foul language, disrespectful behavior, threats of any type of abuse and inappropriate physical contact. Any such behavior may result in expulsion from the event at the expense of the participant & guardians. Such behavior will also warrant probation from any future Youth Ministry activities at the discretion of the Youth Minister. I understand that my luggage and belongings may be subjected to inspection by the Youth Minister or any other adult volunteers of the same sex prior to and throughout the trip.
Signature *

Clear
I hereby authorize my son/daughter to attend Fall Retreat November 4-6, 2022 at Redemption Ranch.

I acknowlege that the $100 payment is non-refundable. I will turn the deposit in by October 23rd.

Make checks payable to Queen of All Saints.
Parent Signature *

Clear
Should be Empty:

Fall Retreat Registration Form

Emergency Contact

Medical

Transportation Permissions