The Parish of Our Lady of Kirkstall

Confirmation Group Retreat

Dates:Friday9 to Sunday 11March 2018Venue:Ampleforth Abbey

The cost of the retreat is £66 per person, however, we would not wish for anyone to be excluded from this activity due to financial circumstances. If there is an issue with regard payment, please contact me in confidence.

We hope to be able to provide transport to Ampleforth although due to numbers, we may need to ask for the assistance of some parents. Further details will be given nearer the time.

Please return this form together with a £30 deposit bySunday 14 January 2018to:the Priest at Sunday Mass,
Su Goodyear (Holy Name Church, 52 Otley Old Road, Leeds LS16 6HW) or Amanda McDonnell (St Mary’s Church, Broadgate Lane, Leeds, LS18 5AB).

You may if you wish pay the amount in full instead of paying the deposit.

Cheques should be made payable to Our Lady of Kirkstall.

If you have any queries, please do not hesitate to contact me at 07533 326111.

Parental Consent

I agree to taking part in this activity.
I acknowledge the need for him/her to behave responsibly and will ensure that he/she is aware of the expected behaviour.
Signed: / Date
Print Name:

Dietary Requirements

Are there any special dietary requirements that your son/daughter has? / YES / NO
If YES, please give details:

Medical Information about Your Child

Does your child have any conditions requiring medical treatment or is your child currently taking any medication? / YES / NO
If YES, please give details:
Is your child allergic to anything (including medication)? / YES / NO
If YES, please give details:
Name and address of family doctor:

Emergency Contact Details

Priority 1 Contact / Priority 2 Contact
Name / Name
Address / Address
Home Tel / Home Tel
Mobile Tel / Mobile Tel
If any of the information given on this form changes prior to the trip, I agree to inform the organisers of the changes prior to departure.
I agree to inform the organiser if, within two weeks prior to departure on the retreat, my son/daughter suffers from any contagious or infectious disease or is in contact with anything that may be contagious or infectious.
I agree to my son/daughter receiving medication as instructed above.
I understand that in an emergency the leaders of the activity will try to contact me but I consent to my son/daughter receiving emergency medical, dental or surgical treatment including anaesthetic or blood transfusion if it is considered necessary by medical authorities present.
Signed: / Date
If required, are you able to offer able to bring your child and offer lifts to other candidates? / YES / NO
If YES, please state any other candidate(s) who is(are) going on retreat who are family friend and who you would normally give lifts to (sports clubs etc):