Visiting Teen Confirmation Retreat Form

Begin Confirmation Registration:

Student Information

Student Name*

First Middle Last Suffix

Gender*

Male
Female

Tshirt*

Grade*

School*

Birthday*

Teen Email*

Teen Phone - (Cell Preferred)*

Mailing Address*

Street Address City State ZIP Code

Medical / Special Needs

Any Special Needs or Medical Conditions*

Yes
No

Describe any allergy, chronic illness, or other condition.*

Taking any Medications*

Yes
No

Please list medications and usage instructions.*

PRIMARY CONTACT - Parent / Guardian Information

Child lives in a...*

1x Parent / Guardian Contact
2x Parent / Guardian Contact

Parent / Guardian Name*

First Last

Relationship to Student*

Example: Mother, Father, Grandmother, etc...

Phone*

Email*

SECONDARY CONTACT - Parent / Guardian Information

Parent / Guardian Name*

First Last

Relationship to Student*

Example: Mother, Father, Grandmother, etc...

Phone*

Email

Emergency Contact

Name*

First Last

Relationship to Student*

Phone*

Alternate Phone

Model Release / Social Media

PERMISSION GRANTED: I hereby grant permission for my child to be photographed and/or videotaped during Confirmation activities and events. I understand that my child may decline to be photographed and/or videotaped at any time. I further grant permission for the resulting photographs and/or videotaped footage to be edited, if necessary, and then published and/or broadcast for the purpose of promoting Confirmation and/or youth programs at St. Joseph Catholic Church. I hereby grant permission for my child to be contacted via phone, SMS, and social media sites such as but not limited to parish websites, Facebook, Twitter, Instagram, Snapchat, Vimeo, and YouTube for the purpose of promoting Confirmation and/or youth programs at St. Joseph Catholic Church and/or to proclaim our faith that Christ is God, the Savior of humanity and of history, the one in whom all things find their fulfillment. I understand that my child may decline to be contacted at any time.
PERMISSION DENIED: I hereby decline to grant permission for my child to be photographed and/or videotaped during Confirmation activities and events. I have instructed my child to decline to be photographed and/or videotaped at all times. I have further instructed my child to notify Confirmation coordinators and/or Core Team / Volunteer Members that he/she may not be photographed and or videotaped under any circumstances. I hereby decline to grant permission for my child to be contacted via phone, SMS, and social media sites such as but not limited to parish websites, Facebook, Twitter, Instagram, Snapchat, Vimeo, and YouTube for the purpose of promoting Confirmation and/or youth programs at St. Joseph Catholic Church and/or to proclaim our faith that Christ is God, the Savior of humanity and of history, the one in whom all things find their fulfillment. I have instructed my child to decline to be contacted at all times. I have further instructed my child to notify Confirmation coordinators and/or Core Team / Volunteer Members that he/she may not be contacted under any circumstances.

I hereby consent to participation by the Student listed above, in the program listed above, under the guidance and supervision of the Director of High School Faith Formation. I understand that the event will take place at the Retreat Center and that my child will be under the supervision of the designated volunteer teachers. I, the undersigned do hereby release forever, discharge, and agree to hold the Diocese of Lafayette, St. Joseph’s Church in Rayne, Leaders, Vehicle Driver(s), Retreat Center, or any Hospital or Medical Center harmless from and against any and all liability, claims, demands, lawsuits and expenses arising from personal injury, sickness, death or property damage of any nature whatsoever which may be incurred or suffered by the undersigned and/or the participant while attending activities. Furthermore, the undersigned assumes all risk of personal injury, sickness, death, damage and expense arising from the undersigned’s or participant’s participation in all activities, including recreation and work activities involved in the above activity. We also allow St. Joseph Parish to provide any and all necessary transportation during the program. We also allow the sponsors to use any photographs taken of the participant during the event in all forms, media and manners, without restriction as to changes or alterations, for advertising, trade, promotion, exhibition or any other lawful purposes. Furthermore, the undersigned agree to indemnify and hold the Diocese of Lafayette, St. Joseph Parish, Leaders, Vehicle Driver(s), Retreat Center, or any Hospital or Medical Center and their respective members, directors, employees and agents (collectively, the “Indemnities”), harmless from and against all claims, demands, actions, lawsuits and liabilities, including attorney’s fees and expenses, sustained by the indemnities as the result of the negligent, willful, or intentional acts of the undersigned and/or participant. If the participant is under 18 years of age: We (I), the parent(s) or legal guardian(s) of the participant, hereby grant permission for our son/daughter to participate fully in the program for which registration is being submitted and all of its undertakings, and hereby give our permission to take said participant to the doctor or hospital and hereby authorize medical treatment, including, but not limited to, emergency surgery, and we, notwithstanding any question of liability involved in this emergency, fully and completely, assume all responsibility for all medical bills. Furthermore, should it be necessary for the participant to return home due to medical reasons, disciplinary action, or otherwise, we (I) assume all responsibility and transportation costs.*

Signature of Parent/Legal Guardian - (Use your mouse or finger on a touch-screen device to sign in the white box below.)

Registration Fees

Confirmation Retreat Fee*

Confirmation Registration 11th grade - $50.00

This fee covers expenses incurred by the Confirmation Retreat.

Total

$0.00

Payment Options

Payment Method*

Venmo @stjoerayne
Drop off Cash/Check

Submit Registration

You will be directed to a confirmation page with further information. Please DO NOT press register button more than once. Doing so may result in multiple billing.

Visiting Teen Confirmation Retreat Registration 2022-2023

Begin Confirmation Registration:

Student Information

Medical / Special Needs

PRIMARY CONTACT - Parent / Guardian Information

SECONDARY CONTACT - Parent / Guardian Information

Emergency Contact

Model Release / Social Media

Registration Fees

Payment Options

Submit Registration