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Confirmation Retreat Registration

- Formation

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- Enter the NUMBER of your children you are registering: REQUIRED Please fill out this field.
  
  STUDENT 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.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Date of Birth xx/xx/xxxx REQUIRED Please fill out this field. Please enter a date.
  
  Student's Cell Phone Number Please enter a phone number.
  
  Medications REQUIRED I hereby GRANT PERMISSION for non-prescription medication (such as Tylenol, Throat Lozenges, Cough Syrup, to be given to my child, if deemed advisable. I understand that Aspirin will not be give to my child. I hereby, DO NOT GRANT PERMISSION for medication of any type, whether prescription or non-prescription, to be administered to my child unless the situation is life threatening or emergency treatment is required. Please fill out this field.
  
  NOTICE: My child will bring all such medications, well labeled, that are necessary. Names of medications and concise directions for seeing that the child takes such medications are as follows: (Enter information in the box below or write none)
  
  Medication and Directions REQUIRED
  List medication and directions or NONE
  Please fill out this field. Please enter valid data.
  
  Accommodations, Support, Health, or Allergy Concerns? REQUIRED
  Please list any health concerns or information you wish for us to know for this child while on retreat. If none, write NONE.
  Please fill out this field. Please enter valid data.
  
  STUDENT 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.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Date of Birth xx/xx/xxxx REQUIRED Please fill out this field. Please enter a date.
  
  Student's Cell Phone Number Please enter a phone number.
  
  Medications REQUIRED I hereby GRANT PERMISSION for non-prescription medication (such as Tylenol, Throat Lozenges, Cough Syrup, to be given to my child, if deemed advisable. I understand that Aspirin will not be give to my child. I hereby, DO NOT GRANT PERMISSION for medication of any type, whether prescription or non-prescription, to be administered to my child unless the situation is life threatening or emergency treatment is required. Please fill out this field.
  
  NOTICE: My child will bring all such medications, well labeled, that are necessary. Names of medications and concise directions for seeing that the child takes such medications are as follows: (Enter information in the box below or write none)
  
  Medication and Directions REQUIRED
  List medication and directions or NONE
  Please fill out this field. Please enter valid data.
  
  Accommodations, Support, Health, or Allergy Concerns? REQUIRED
  Please list any health concerns or information you wish for us to know for this child while on retreat. If none, write NONE.
  Please fill out this field. Please enter valid data.
  
  STUDENT 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.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Date of Birth xx/xx/xxxx REQUIRED Please fill out this field. Please enter a date.
  
  Student's Cell Phone Number Please enter a phone number.
  
  Medications REQUIRED I hereby GRANT PERMISSION for non-prescription medication (such as Tylenol, Throat Lozenges, Cough Syrup, to be given to my child, if deemed advisable. I understand that Aspirin will not be give to my child. I hereby, DO NOT GRANT PERMISSION for medication of any type, whether prescription or non-prescription, to be administered to my child unless the situation is life threatening or emergency treatment is required. Please fill out this field.
  
  NOTICE: My child will bring all such medications, well labeled, that are necessary. Names of medications and concise directions for seeing that the child takes such medications are as follows: (Enter information in the box below or write none)
  
  Medication and Directions REQUIRED
  List medication and directions or NONE
  Please fill out this field. Please enter valid data.
  
  Accommodations, Support, Health, or Allergy Concerns? REQUIRED
  Please list any health concerns or information you wish for us to know for this child while on retreat. If none, write NONE.
  Please fill out this field. Please enter valid data.
- Parent / Guardian
  
  Parent / Guardian Name REQUIRED Please fill out this field. Please enter valid data.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  Parent / Guardian 2 Please enter valid data.
  
  Email Please enter an email address.
  
  Phone Number Please enter a phone number.
- INSURANCE
  
  If no insurance, write NONE in the following boxes.
  
  Insurance Name REQUIRED Please fill out this field. Please enter valid data.
  
  Insurance Group Number REQUIRED Please fill out this field. Please enter valid data.
  
  Insurance Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  Name of Policy Holder REQUIRED Please fill out this field. Please enter valid data.
- Emergency Contact (Not parents)
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  Relationship to Child REQUIRED Please fill out this field. Please enter valid data.
  
  Family Doctor's Name REQUIRED Please fill out this field. Please enter valid data.
  
  Physician's Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Medical Consent:
  In the event of an emergency, I hereby give permission to the staff of Sts Peter & Paul Catholic Church to seek emergency medical transport and/or treatment for my child(ren) named above. I will be responsible for all costs incurred. I wish to be advised before further care is given by the hospital or doctor.
  I Agree Please select this field.
- Video/Photography Consent
  As parent/guardian, I understand that promotional pictures and videos ( individual and group) may be taken during the classes and activities. I give permission for my child(ren)'s pictures (named above) to be used for church promotional materials such as newsletters, web pages, calendars, Power Point presentations, or videos to promote or highlight activities of the children in their Faith Formation classes, Sacramental Preparation, and Retreats.
  I Agree Please select this field.
- Consent and Liability Waver
  In the event of any accident or injury, I agree on behalf of myself, my child(ren)'s other parent if known or living, the child(ren) named above or our heirs, successors, and assigns, to hold harmless and defend the Archdiocese of Galveston-Houston, its pastor or any representative of Faith Formation and Youth Ministry, unless the parties involved were careless and negligent. Effective for all Faith Formation and Youth Ministry activities at Sts. Peter & Paul Catholic Church.
  I Agree Please select this field.
- I, the parent named above, grant permission for my child to participate in the Confirmation Retreat to be held between Jan 15-17th, 2021 at both Sts Peter and Paul Parish in Bellville, Texas and Cat Spring Retreat Center in Cat Spring, TX.
  
  In signing this form I hereby certify that the above information is true and accurate to the best of my knowledge.
- Parent / Guardian Electronic Signature REQUIRED Please fill out this field. Please enter valid data.
Submit

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Submission

BE SURE TO HIT SUBMIT BUTTON ABOVE. You should get a confirmation email at the address you entered for Parent 1.
PAYMENT

PAYMENT will be TAKEN on the SPP Giving Page. Click the payment button below and CHOOSE "Confirmation Retreat Fee" in the drop down menu to process your total payment there.

RETREAT FEE is $105. Please contact us if you need financial assistance.

ONLINE RETREAT PAYMENT

CASH or CHECK to Sts Peter and Paul - this can be dropped of in our lock box at the rectory anytime or given to a staff member during business hours.

Registration is not complete without payment of $105. Those in need of financial assistance or with questions please contact, Cynthia Luongo 713-299-1299

FINAL DUE DATE Jan 6th