Middle School Retreat

Please enter the name of the young person attending the reterat. If more than one person from your family is attending the retreat, please complete a form for each young person.

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

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

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

Please list the allergies or food restrictions your child. Please enter valid data.

Parent(Guardian) Information

First Name Please enter valid data.

Last Name Please enter valid data.

Parent Email

Thank you for confirming your middle schoolers participation in the upcoming retreat. If you volunteered to help, you will receive an email by February 6th with further instructions.

Please enter an email address.

Parent Phone Number Please enter a phone number.

Name and Phone Number for other Parent/Guardian or other Emergency Contact.

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

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

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

Please let us know how you can help with the retreat. REQUIRED I am not able to help at this time. Check-In Table Lunch Chaperone 12:30 - 2:30 Chaperone 2:30 - 4:30 I will donate cookies for lunch. I will donate snacks for break time. I will help with clean up. Please fill out this field.

I grant permission to the Faith Formation and Youth Ministry staff and its designated representatives to take photos and video of my child(ren) for use in parish publications, parish website and social media. REQUIRED Please fill out this field.

I, the parent or legal guardian of this young person authorize the employees, representatives and chaperones of St. Kateri Tekakwitha Parish to obtain emergency medical treatment, should it be necessary, during my child’s attendance and participation in the Celebrating Saints Middle School Retreat.

I understand that I will be notified immediately should it become necessary to obtain emergency treatment.

I Agree Please select this field.

In consideration of my child’s attendance and participation, I hereby, for myself, my heirs, executors, administrators and assigns, waive and release any and all claims for damages I may have against St. Kateri Tekakwitha Parish, the Roman Catholic Diocese of Albany, New York,
their representatives, chaperones, employees, successors and assigns arising out of any and all injuries by my child while participating in this activity/program.

I Agree Please select this field.

I understand that I will by notified at the time of any violations requiring your young person to be dismissed from the program/activity.

I Agree Please select this field.

Saint Kateri Tekakwitha Parish

2216 Rosa Road || Schenectady, NY || 1803 Union Street

Middle School Retreat