Download the Form - Dual Saints Antioch

March 6th – 8th, 2015
All high school youth in the Greater Lafayette area are invited to attend the Spring Antioch Retreat, an awesome
weekend led by high school youth who have previously attended Antioch.
We promise you’ll have a good time, so sign up today!
The 2015 Spring Antioch Retreat will take place on the weekend of March 6th - 8th at Saint Lawrence Catholic
Church from 7:00 pm Friday through 3:30 pm Sunday. Youth will stay at host homes Friday and Saturday nights.
You will receive a detailed packing list once your registration is received. Please return this form and
payment to the Antioch Team or the St. Lawrence or St. Mary Parish Office by Friday, February 20th.
COST: $40.00, includes all meals, shirt, various supplies, and a very fun weekend!
(For financial assistance, please contact Sue as listed below.)
In order to keep the cost of the retreat to a minimum, we ask that everyone bring a 2-liter of pop or package of
juice boxes, plus an item for meals indicated by last name as follows:
A-H: Bag of Candy | I-P: 1 Block of Cheddar Cheese | Q-Z: Non-Chip Snacks: (Cookies, Snack Cakes, Fruit Roll-Ups, etc)
For more information, go to
For questions and how to be a host home, contact Sue Bayley at (765) 404-0753 or
NAME: _____________________________________ GENDER(circle): M F AGE: ______ GRADE: ______
PARISH: ___________________________________ SCHOOL: ____________________________________
ADDRESS: ____________________________________________ CITY/ZIP: __________________________
PARENT’S NAME: ___________________________________ T-SHIRT(circle): S
PARENT’S PHONE: __________________________ PARENT’S E-MAIL: ____________________________
MEDIA CONSENT: We believe that both the youth and the parish benefit from positive recognition. There
may be occasion for media coverage concerning your youth throughout the year in newspapers, newsletters, our
website, etc. This includes presence in photos, videos, and occasional audio. Names will not be associated with
any media (photos, videos, audio, etc) without direct permission.
____ Yes The parish may release retreat related info involving my youth to the media.
____ No The parish may not release retreat related info involving my youth to the media.
We, as parents/guardians of the undersigned minor, hereby consent and agree to hold harmless Saint Lawrence Catholic
Church and/or the Roman Catholic Diocese of Lafayette-in-Indiana, Inc., and any and all employees or volunteers thereof,
for any accident, injury or occurrence arising out of, or in connection with the aforementioned activity.
I give my permission for son/daughter, in case of an emergency, to be taken to a physician or hospital by an adult retreat
member. I understand that every effort will be made to contact me. If I cannot be reached, I hereby give permission to the
physician selected by the adult retreat member to secure proper treatment for my child.
My child may be given: PLEASE CHECK ONE
___ Over the Counter (non-prescription) medication (Tylenol, cough drops, Benadryl, etc.)
___ No medication unless emergency treatment is required
Allergies or Other Medical Info: ____________________________________________________________
Hospital Preference: __________________________ Youth’s Physician: ___________________________
Emergency Contact Name: _____________________________________ Phone: ____________________
Medical Insurance Provider: __________________________ Policy Number: _______________________
By signing below, I, the parent/guardian of the youth who will be attending the retreat, acknowledge and agree that all
information on this form is correct and accurate.
Parent/Guardian Signature: _________________________________________ Date: ________________