St. Demetrius CCG
Faith Break Youth Retreat Registration Form
February 23-25, 2018
Family Form (please print a second form if required)
Youth 1
Given Name______Family Name______
Date of Birth (yyyy/mm/dd) ______Age ____
Gender: Male □ Female □
Youth 2
Given Name______Family Name______Date of Birth (yyyy/mm/dd) ______Age ____
Gender: Male □ Female □
Youth 3
Given Name______Family Name______Date of Birth (yyyy/mm/dd) ______Age ____
Gender: Male □ Female □
*For the children’s safety a recent photo of each child is required to be attached.
Address______
City______Postal Code______Telephone ______
Parent/Guardian Name 1______
Home phone______Work Phone______
Email ______
Parent/Guardian Name 2______
Home phone______Work Phone______Cell______
Email ______
Alternative/Emergency Contact______
Relationship to youth: ______
Home phone______Work phone______Cell______
Health Card Number
Youth 1______Youth 2______Youth 3______
Please list any medications per youth (If medication is required consent to administer medication form needs to be completed and staff need to be reminded at drop off, daily)
1. ______
2. ______
3.______
Please indicate if youth experiences or has experienced any of the following:
Condition (Please indicate Yes/No and Details)
Seizures
ADHD/ADD
Asthma
Diabetes
Physical limitations
Major Illness/Surgery
Other Health Issues
ALLERGIES: / *************************** / *************************** / ***************************
Nuts
Bee Stings
Latex
Food
Other
Youth Retreat Fee $80.00 (Actually cost for the weekend is $112.00/per participant St. D’sCCG will be covering the remaining $32.00/participant)
Please make cheques payable to “St. Demetrius Church Community Group”
Authorizations: In the unlikely event that the participant(s) named above is injured or becomes seriously ill while with the St. Demetrius Community Church Group Faith Break Youth Retreat, and I cannot be reached, I authorize St. Demetrius CCG Youth Retreat senior staff/leaders to seek and authorize any and all hospitalization, medical dental and/or surgical treatment deemed advisable by the circumstances. While every reasonable precaution is taken with St. Demetrius CCG Youth Retreat programs, it is agreed that the St. Demetrius CCG Youth Retreat and its staff and volunteers are released from all liability for injury to the above named participant or for loss or damage to personal property.
Signature of parent/guardian ______Date______
I grant the release to the St. Demetrius CCG Youth Retreat and the affiliated the right to use photographs and/or video tape in which I and/or my child appears for the use in publicity brochures, newsletters, annual reports or any materials and articles promoting the St. Demetrius Youth Retreat, its programs and membership.
Signature of parent/guardian ______Date______
For Office Use Only:Fee Paid ___ Amount ______Cash ___ Cheque ___ # ______Photo attached YES/NO
Received by: ______Date: ______
Drop off/Pick up
Retreat begins Friday, February 23, 2018 at 6:00pm (We expect participants will be arriving between 6:00 & 7:00pm)
Participants are to be dropped off at the Main building (School House) on Mount Mary grounds.
Mount Mary Retreat Centre
437 Wilson St. E., Ancaster, ON, L9G 3K4
Coming from the East: 401/ 403/ QEW/ 407 (Toronto)
To 403 West (Hamilton/ Brantford):By-pass all Hamilton exits, continue up the escarpment. 1st exit to Ancaster off the 403 is “Lincoln Alexander Parkway & Rousseaux Street” (formely Mohawk). Bear right for Rousseaux exit. Proceed through two sets of lights. At the end of Rousseaux St. (third set of lights) turn left on to Wilson St. East. Turn right at the large stone gate (That’s the Retreat Centre’s entrance gate).
Upon entering the grounds drive straight along the driveway and you will see the school house on your right, there is parking just past the school house. If you come to a circular driveway you have gone too far and are at the Sister’s residence.
Pick up of participants is on SUNDAY, FEBRUARY 25, 2018 promptly at 1:00pm.
Participants will be well nourished with 3 well balanced meals and snacks throughout the day. There is no food allowed in the dormitory please do not pack any snacks for your children unless required for medical reasons.
What to Bring
1. INDOOR SHOES!
2. Alarm clock
(Optional; if you require more time to get ready in the morning; all participants will have a 7:30am wake up & breakfast is at 8:00am)
3. Extra blanket or sleeping bag
4. Pillow
5. Towels
6. Toiletries (there are full bathroom facilities with shower)
7. Comfort from home
8. WARM CLOTHES, we will be participating in outdoor play, all youth will be participating.
Snow pants
Ski jacket
Hat
Scarf
Mittens &/or warm gloves
Snow Boots
9. Warm, modest pajamas.
10. Toboggan (optional)
IMPORTANT!
THERE IS A STRICT NO ELECTRONICS POLICY FOR THE RETREAT THIS INCLUDES
· SMART PHONES
· ANY AND ALL VIDEO GAME SYSTEMS
· TABLETS/IPADS/LAPTOPS/NOTEBOOKS ETC.
· MP3 PLAYERS
· RADIOS
· STEREOS/CD PLAYERS
ELECTRONICS FOR MEDICAL PURPOSES ARE ACCEPTABLE.
ELECTRONICS FOUND ON PARTICPANTS WILL BE CONFISCATED AND RETURNED UPON DEPARTURE OF RETREAT.
In case of emergency participants may be contacted via
416-826-3021(retreat leader) or 905-648-4485 (Mount Mary, Ancaster)