C.O.R. Registration

C.O.R. Registration
Confirmation Overnight Retreat
Saturday, January 18th 8 AM – Sunday, January 19th 4:30 PM
Bishop Lane Retreat Center
7708 East McGregor Rd, Rockford, IL 61102
Parent/Guardian Name *

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

Area Code Phone Number
Participant's Name *

First Name Last Name
Birthdate *

Month Day Year
Date
Gender *

Female Male
T-shirt Size (adult) *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Medical and Permission Form
I grant permission for the administration of First Aid to my youth by the people in charge of the event, and those transporting my child to and from the event as their judgment deems advisable, and to make the necessary referrals to qualified physicians for the treatment of illness or accidents of a more serious nature. I understand I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life. In the case of a medical emergency, I understand that every effort will be made to contact the parent/guardian of the participant. In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult staff to hospitalize, secure proper treatment for and to order injection, anesthesia, or surgery deemed necessary for my child.
Allergic to any medications? *

Yes No
If yes, please explain: *
Medications participant is currently taking: *
Insurance Information
Policy in the name of: *
Policy Number *
Identification Number *
Authorized physician *
Physician Phone Number *

Area Code Phone Number
In case of emergency, we will contact the parent/guardian named above first. We ask that you provide an alternate contact just in case.
Alternate Emergency contact: *

First Name Last Name
Emergency contact phone number: *

Area Code Phone Number
Parent Signature *

Clear
I give permission for my son/daughter to attend the

Confirmation Overnight Retreat

Saturday, January 12th 8 AM – Sunday, January 13th 3 PM

Bishop Lane Retreat Center

7708 East McGregor Rd, Rockford, IL 61102

I hereby release and indemnify my parish, St. Margaret Mary in Algonquin, IL its staff, volunteers and the Diocese of Rockford from any and all liability arising from claims of any kind or nature whatsoever from my child’s participation in this event.

Videotaping and Still Photographs
Video and still photographs may be taken during this event. This authorization form constitutes permission for my youth’s participation in the videotape and or still photographs, which may be used for future promotional efforts, including the Diocese of Rockford website and St. Margaret Mary website.

Code of Behavior
As a participant in this event, he or she is representing our parish during this event and we expect he/she will represent us well. We expect that he/she will display mature and responsible behavior, which for many years has been the trademark of Catholic youth and adults of our diocese.

Some expectations:
1. All participants are expected to arrive on time.
2. All participants are expected to demonstrate common courtesy and respect at all times.
3. Inappropriate language/ behavior will not be tolerated.
4. Socializing should always be done in public.
5. Dress should reflect the value of modesty. Writing on clothing should reflect Christian values.
6. The possession or consumption of any alcoholic beverage and/or possession/use of any illegal drug is not permitted.
7. Smoking is not permitted.
8. Weapons and/or drug paraphernalia are not allowed.
9. If under the age of 18, prescription drugs need to be given to an adult for storage and distribution.
10. Infraction of these rules can mean immediate dismissal with no refund. Participants will be responsible to local authorities as well.
I understand and agree to this Code of Behavior. I also understand and agree that at the time of an infraction requiring dismissal, I am responsible for my removal from the premises and any costs involved.

If under the age of 18, I also understand and agree that my parents or guardian will be notified at the time of an infraction requiring my dismissal. My parents or guardian will be responsible for my removal from the premises and any costs involved.
Youth Signature *

Clear
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date
Payment

The cost for this event is $115. There is a non-refundable deposit of $25 or you can pay in full.
Please follow the link to submit your payment on GiveCentral. Once you have paid, please click the submit button below to complete you registration.

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C.O.R. Registration

Medical and Permission Form

Payment