RETREAT REGISTRATION:
Participant Name: _______________________________________________________
Adult Name (if attending)_______________________________________________
Parish_______________________________________________
Phone_______________________________________________________
Email________________________________________________________
PAYMENT INFORMATION:
The cost for the retreat is $125 and covers all lodging, meals, and supplies for the weekend. Checks should be payable to the Diocese of Greensburg. Please note that registrations are not complete until the registration form and fee have been turned in to Kirsten Lieberum or Mary Blythe at St. Agnes Church, 11400 St. Agnes Lane, N. Huntingdon, PA, 15642. All retreat payments must be received in full by February 6, 2012.
CANCELLATION AND SUBSTITUTION POLICY:
Registrations cancelled prior to two weeks before the retreat start date incur no penalty. Registrations cancelled 13 days or less including the retreat start date will incur a $100 penalty. No shows will not receive a refund. Substitutions are acceptable up to the day before the retreat.
SCHOLARSHIP OPPORTUNITIES:
Youth applicants are welcome to apply for Francis Fund scholarship if they are in need of financial assistance. The deadline for the Francis Fund applications is January 2, 2012. Applications are available on the Diocesan website: www.dioceseofgreensburg.org.
CHAPERONE POLICY AND PERMISSION:
Please note: The adult to student ratio is 7:1. All adults attending must comply with the Diocesan Child Protection Policy. Youth must be accompanied by a parish chaperone. All youth in attendance must have a completed permission form. It is to be sent with the registration form.
QUESTIONS?:
Contact Kirsten Lieberum at 724-787-4437; klieberum@dioceseofgreensburg.org
Mary Blythe at (724) 864-5393; mblythe@dioceseofgreensburg.org
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NUMBER |
COST |
Total Due |
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YOUTH REGISTRANTS |
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X $125.00 |
$ |
|
ADULT REGISTRANTS |
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X $125.00 |
$ |
TOTAL AMOUNT DUE $_________
____Yes, we would like transportation by bus to the retreat. The bus will depart from Our Lady of Grace Parish in Greensburg at 6:30 PM.
____No, we will provide our own transportation to Jumonville.
ROOMING ASSIGNMENTS
Youth rooms may have 3, 4, or 5. There are a limited number of rooms with 6 and 7 beds. Those will be assigned on a first come, first serve basis.
If there are less than 3 in a youth room, they will likely be assigned roommates from another parish.
Adult rooms should have no more than three adults.
rYOUTH ROOM r ADULT ROOM rYOUTH ROOM r ADULT ROOM
rMALE r FEMALE rMALE r FEMALE
1. ________________________________ 1. _________________________________
2. ________________________________ 2. _________________________________
3. ________________________________ 3. _________________________________
4. ________________________________ 4. _________________________________
5. ________________________________ 5. _________________________________
6. ________________________________ 6. _________________________________
rYOUTH ROOM r ADULT ROOM rYOUTH ROOM r ADULT ROOM
rMALE r FEMALE rMALE r FEMALE
1. ________________________________ 1. _________________________________
2. ________________________________ 2. _________________________________
3. ________________________________ 3. _________________________________
4. ________________________________ 4. _________________________________
5. ________________________________ 5. _________________________________
6. ________________________________ 6. _________________________________
rYOUTH ROOM r ADULT ROOM rYOUTH ROOM r ADULT ROOM
rMALE r FEMALE rMALE r FEMALE
1. ________________________________ 1. _________________________________
2. ________________________________ 2. _________________________________
3. ________________________________ 3. _________________________________
4. ________________________________ 4. _________________________________
5. ________________________________ 5. _________________________________
6. ________________________________ 6. _________________________________
rYOUTH ROOM r ADULT ROOM rYOUTH ROOM r ADULT ROOM
rMALE r FEMALE rMALE r FEMALE
1. ________________________________ 1. _________________________________
2. ________________________________ 2. _________________________________
3. ________________________________ 3. _________________________________
4. ________________________________ 4. _________________________________
5. ________________________________ 5. _________________________________
6. ________________________________ 6. _________________________________
PARENT-GUARDIAN CONSENT/RELEASE FORM
We, the parents/guardians of ____________________________ do hereby give our
permission
for him/her to attend The 2012 Diocesan Youth
Retreat on February 24-26, 2012
Parent/Guardian Signature______________________________
Parent/Guardian Signature______________________________
We do hereby release and forever discharge the Diocese of Greensburg and designated chaperones from any/all actions or suits in law or equity which we might hereafter have by reasons of injuries sustained by our son/daughter participating in the above mentioned activity. In case of emergency, we give permission for our child to be treated at a hospital and/or by a medical doctor.
In case of emergency, contact us at this phone number: _______________________________
If we are unavailable, contact (name) ______________________ phone number __________
Our Insurance Company is _______________________________policy number___________
Date__________________ Parent/Guardian Signature______________________________
Parent/Guardian Signature______________________________
PLEASE COMPLETE THE FOLLOWING INFORMATION:
Student Name_________________________________________ Home phone____________
Address______________________________________City_____________________Zip_____
Age______Grade______High
School/City__________________________________________
Parish/City___________________________________________________________________
Indicate any illness or allergies of which we should be aware. Also, if the student will be taking any prescription medication, please note below:
PHOTOGRAPHIC RELEASE LETTER
I hereby grant to the Diocese of Greensburg, Pennsylvania, and its respective licensees, successors and assigns, the right and permission, with respect to those photographs taken of me or the minor named below on whose behalf I am signing, and with respect to any printed or electronic matter in connection therewith, to do the following:
- To include such photographs on the Diocese of Greensburg website and on print material
- To use my name, or the name of the minor on whose behalf I am signing, in connection with the foregoing.
I hereby release, discharge and agree to indemnify and hold harmless the Diocese of Greensburg and its legal representatives, licensees, successor and assigns, from all claims and demands whatsoever arising out of or in connection with the foregoing, and waive any right to inspect or approve the same.
__________________________________________
Signature of Adult Photographed or Parent and/or Guardian
I hereby certify that I am the [parent and/or guardian] of ______________________________, a minor under the age of eighteen years, and hereby consent on behalf of said minor to the use of any of the photographs taken of said minor pursuant to the terms set forth in this Photographic Release, including, without limitation, the release, discharge and hold harmless provisions thereof.
__________________________________________
Signature of Parent and/or Guardian
FULL-FILLED RETREAT PACKING LIST & IMPORTANT INFORMATION
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WHAT TO BRING: |
WHAT NOT TO BRING |
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MEALS: |
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Friday: Snack |
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Saturday: Breakfast, Lunch, & Dinner |
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Sunday: Breakfast & Lunch |
-Please pray for this retreat. Prayer can make a retreat a lot better and lack of prayer can make a retreat lack the potential it would have with prayer.
-Invite more people – we still have lots of room and friends are welcome.
-When it’s time to go to bed, you go to bed. This is taken seriously.
-When it’s time to pray, you pray. When it’s time to play you play!
-Although we don’t expect this, there is no tolerance for misbehaving, disrupting the retreat, or hurting anyone. Stealing, fighting, swearing, immodesty, inappropriate behavior, going into areas where your gender is not allowed, disrespect or disobedience to Retreat Leaders, Chaperones, or anyone else will not be tolerated.
***Parents will be called to pick you up at the Retreat Leaders’ or Diocesan Director’s discretion.
PARENTS: IF YOU NEED TO GET A HOLD OF YOUR CHILD OR THE RETREAT CENTER PLEASE CALL THE PARISH GROUP LEADER’S CELL PHONE NUMBER. PLEASE MAKE SURE YOU HAVE THIS NUMBER BEFORE YOUR CHILD IS DROPPED OFF FOR THE WEEKENED. OTHER EMERGENCY CALLS CAN BE DIRECTED TO THE JUMONVILLE RETREAT OFFICE AT 724-439-4912.