Middle School Overnight Retreat Registration 2017

Name of Event: Middle School Faith Formation Overnight Retreat
Location: Little Pine Island Camp - Little Pines Lodge, 6889 Pine Island Drive NE, Comstock Park, MI 49321
Supervisor of Activity: Josh Hanson
Date, Time, & Drop Off: Friday, March 16, 2018, 6:30 PM, Little Pines Lodge
Date, Time, & Pick Up: Saturday, March 17, 2017, 5 PM, Little Pines Lodge
Method of Transportation: Own
Cost: $30
What to Bring: A pack list will be sent before the retreat
Description of Event: The overnight retreat is a longer retreat designed to further deepen our middle school youths’ relationship with Jesus Christ. The extra time on an overnight retreat gives youth an opportunity to get away from the busy world in order grow with one another in our faith. This retreat will include Mass, Confession, great speakers, music, praise & worship, small group time, ice breakers, games, & more! Please check the website and bulletin for permission forms & more information!

Student Name:
Address: , , MI,
Allergies, Restrictions or Recommendations


Parent/Guardian Name:
Parent Phone: or
Parent Email:
I certify that I am the of the minor child named above and I agree to the above terms for myself and for my minor child.

Emergency Contact other than parent:
Emergency Contact will only be contacted if parent is not available

Family Physician:

Health Insurance Data
**If your policy does not have some of these areas of information, please enter NONE**
Policy Number:
Group Number:
Contract Number:

Consent for Participation:
I hereby consent to participation by my child in the event described above. I understand that this event will take place on parish grounds. I further consent to the conditions stated above on participation in this event, including the method of transportation.

In consideration of my child being allowed to participate in this event, I agree to waive and release, and indemnify and hold harmless Our Lady of Consolation Parish, any and all affiliated organizations, its/their employees, agents, representatives, volunteers and drivers, from any and all claims I or my child may have, excluding claims for intentional misconduct or gross negligence, arising from or relating to my child’s participation in this event.

Consent for Medical Treatment:
As a parent/guardian, I do hereby authorize first aid/medical treatment of my child in the event of an emergency which may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed. It is understood that efforts will be made to reach me as soon as reasonably possible.

Consent for Photo & Media Consent:
As legal guardian of the aforementioned child to participate in the Our Lady of Consolation Parish Formation Programming. I understand that photography and/or video of participants may be procured during Formation Programming and used in promotional materials. I consent to the use of images and likenesses of the aforementioned person, for promotion purposes by Our Lady of Consolation Parish, including the Our Lady of Consolation Parish website and Facebook page.

Would you be interested in helping with this retreat?

If yes, how would you like to help with this retreat?
All Day ChaperoneLunch Prep and ServingSnack Prep and Serving