2022 Survivor Retreat Registration

2022 Survivor Retreat Registration Form & Payment

Saturday, July 30th - 10am-2pm
Outwit, Outplay and Outlast! Enjoy games and activities as we journey with Paul through his shenanigans and trials. Learn to persevere through life's challenges with a Survivor-themed retreat just for you!

Open to all Catholic girls ages 10 to 18. Retreat will take place in the Great Hall at St. Francis and includes lunch
Register TODAY. Space is limited.

Participant First Name

Participant Last Name

Birthdate

Age

Address

City

State

Zip Code

Participant Email

Participant Cell Phone

Grade

Name of School

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Parent/Guardian Cell Phone

Parish

Parish City

Diocese

Year(s) Registered @ Parish

Emergency Contact

Emergency Contact Cell Phone

Relation to Emergency Contact

Is Contact Authorized for Pick Up?

Primary Care Physician/Practice

Primary Physician Phone

Preferred Emergency Hospital

Allergies? Please explain.

Upload Insurance Card

Upload File

I agree to the CONSENT TO PARTICIPATE AND RELEASE USAGE OF AUDIO/VISUAL RECORDING AND PHOTOGRAPHYView terms here

I agree to AUTHORIZE CONSENT TO TREAT A MINORView terms here

I agree to the COVID-19 STATEMENTView terms here

Parent/Guardian Signature (First and Last Name)

Thank you for registering!