Girls Retreat

Parent

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Email REQUIRED Please fill out this field. Please enter an email address.
Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.

Emergency Contact (other than parent)

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Relationship to Child REQUIRED Please fill out this field. Please enter valid data.

Number of Teens Registering REQUIRED Please fill out this field.
Teen 1
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Grade Level REQUIRED Please fill out this field.
- Please list any allergies and/or dietary restrictions. Please enter valid data.
- Do you anticipate your child will need to take medication during this event? REQUIRED Yes No Please fill out this field.
Teen 2
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Grade Level REQUIRED Please fill out this field.
- Please list any allergies and/or dietary restrictions. Please enter valid data.
- Do you anticipate your child will need to take medication during this event? REQUIRED Yes No Please fill out this field.
Teen 3
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Grade Level REQUIRED Please fill out this field.
- Please list any allergies and/or dietary restrictions. Please enter valid data.
- Do you anticipate your child will need to take medication during this event? REQUIRED Yes No Please fill out this field.
Teen 4
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Grade Level REQUIRED Please fill out this field.
- Please list any allergies and/or dietary restrictions. Please enter valid data.
- Do you anticipate your child will need to take medication during this event? REQUIRED Yes No Please fill out this field.

MEDIA RELEASE

On occasion, St. Alphonsus Liguori Catholic Church takes photographs or makes an audio or video recording of children and/or adults involved in parish activities. Images may be used on parish print, electronic, and social media platforms.

I expressly grant to St. Alphonsus Liguori Catholic Church the right, privilege and license to use the picture or likeness of my child/children in any photograph, movie, video production or any other forms of media publication and to use the verbal or written statements or declarations of my child/children for the purpose of publicizing, fostering and promoting the parish and its programs.
Please answer according to the publicity statement above: REQUIRED Yes No Please fill out this field.

LIABILITY RELEASE

As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“participant”). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend the Diocese of Lafayette-in-Indiana, its officers, directors, employees and agents, chaperones, or representatives associated with the event, from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the Diocese of Lafayette-in-Indiana, its officers, directors, its employees and agents, chaperones, or representatives associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the Diocese of Lafayette-in-Indiana.
Please answer according to the liability statement above: REQUIRED Yes No Please fill out this field.

MEDICAL RELEASE

We give our permission for our son/daughter, in case of emergency, to be taken to a physician or hospital by either a parent in charge or by parish personnel. We understand that every effort will be made to contact us. If we cannot be reached, we hereby give permission to the physician selected by the parish member in charge or adult chaperone(s) to secure proper treatment for our son/daughter.
Please answer according to the liability statement above: REQUIRED Yes No Please fill out this field.

Registration Form Consent - Parent/Guardian First and Last Name REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED Please fill out this field. Please enter a date.

Refund Policy REQUIRED I understand that my payment is non refundable should my teen be unable to attend the retreat. Please fill out this field.

Girls Retreat

About Dwell

What will our time together include:

The Details:

Girls Retreat Registration Form