8/8/2019 K-1 Retreat Ant Application

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KAIROS RETREAT for Juniors and Seniors

APPLICATION 

K-1 = March 4-6, 2011 – Due NO LATER THAN Feb. 16, 2011 –

but the sooner the better!!!!! 

 Remember this is open to the first 30 registrants, so be sure to sign upquickly if you are interested in attending.

STUDENT NAME: ____________________________________________

STUDENT E-MAIL: _____________________________________________________

PARENT E-MAIL: _______________________________________________________

ADDRESS: ________________________________CITY:_______ ZIP:________

SCHOOL: ____________________________________________ Grade: _____________

HOME TELEPHONE: __________________PARENT’S WORK PHONE: ___________________STUDENT CELL: _________________________ PARENT CELL:_____________________

RETREAT PROGRAM: This is a special "time of the Lord". This is what the word "KAIROS" means. It is a Christian experience of prayer and reflection, run by the youth director (KyleKuckelman), the youth ministries intern, adult volunteers and students. Student responsibilityand commitment are essential to the effectiveness of the retreat.

Please answer the following question:

1. Why do you wish to attend the Kairos retreat?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

A LIMITED NUMBER OF RESERVATIONS ARE AVAILABLE FOR EACH SESSION.

This form should be returned to Kyle Kuckelman to reserve your spot. Please drop off inthe church office at Sacred Heart of Jesus or mail to:

Sacred Heart of Jesus

Attn: Kyle Kuckelman – Youth

5501 Monticello Rd.Shawnee, KS. 66226

If a conflict arises once you are registered please contact Kyle immediately to allow anyone on a waiting list to attend.

COST:  Because of the length of the program (three days – Friday after school through Sunday approx. 8p.m), it is necessary to charge $100.00 to help cover the costs. No student will be turned down because

of money! Please see Kyle if money if you would like a scholarship application. 

8/8/2019 K-1 Retreat Ant Application

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PARENTAL/GUARDIAN LIABILITY WAIVER AND HEALTH FORM

COST: Because of the length of the program it is necessary to charge $100.00 to helpcover the costs. No student will be turned down because of cost! Please contact KyleKuckelman (913-422-5600) if unable to cover fee at this time as scholarships are

available. Email shyouth@shoj.org.

PARENT PERMISSION: I hereby give my son/daughter permission to participate in theKairos Retreat Program, coordinated by Sacred Heart of Jesus and held at the Savior

Pastoral Center. I also give him/her permission to utilize the transportation supplied bySacred Heart of Jesus to and from the retreat center. I hereby release the Archdiocese of Kansas City in Kansas, Sacred Heart of Jesus, and all sponsors, chaperones, aides andothers connected from any and all claims arising out of or from any accident oroccurrence, causing injury to any person or property, during this event. In the event mychild is dismissed from this event for any reason, I am responsible for his/hertransportation home. I understand my child’s obligation to participate in the retreat

from start to finish.

_________________________________________________________________(Signature – Mother’s / Father’s or Guardian Date Emergency Phone #

Please list any medical concerns, or other information that would be helpful for the adultsdirecting the retreat.________________________________________________________________________________________________________________________________________________________________________________________________________________________

My child may be given these non-prescription products if needed.(Circle any or all)

Tylenol Advil Tums Pepto-Bismol Other -____________________________

NONE - No medication may be given unless emergency treatment is required.

Parent Signature - ___________________________________

Parent E-mail address - ________________________________

Parent Home Phone number - ___________________Cell - _________________