Called and Sent Retreat

Name: Called and Sent Retreat
Start: 2023-07-23T00:00:00-05:00
End: 2023-07-26T23:59:59-05:00

July 23 - July 26

The Man of the Shroud Exhibit coming to Vandalia »

Name: Called and Sent
Dates: Sunday, July 23 - Wednesday, July 26, 2023
Who: Anyone in 9th-12th grade in Fall of 2023.
What: Join your peers on a brief but powerful retreat to hear the Lord and go live out his will.
Location: Villa Maria Retreat Center, Springfield, IL.
Cost: $200.00. "Submit" button leads to payment form.

Arrival/Departure

Arrival: 5:30 P.M. on Sunday, July 23^rd.
Departure: 3:00 P.M. on Wednesday, July 26^th.

Register

Name(Required)

First Last

Gender(Required)

Male

Female

Date of Birth(Required)

Grade you will be in Fall, 2023(Required)

Participant Email(Required)

Phone(Required)

Parish(Required)

Name of parent(s)/guardian(s)(Required)

First Last

Address of parent(s)/guardian(s)

Street Address Address Line 2 City State ZIP Code

Email of parent(s)/guardian(s)(Required)

Phone of parent(s)/guardian(s)(Required)

Hidden

Name of Medical Insurance(Required)

Hidden

Policy #(Required)

ADDITIONAL EMERGENCY CONTACT INFORMATION: Name and phone number of an adult to reach in case of emergency in the event that you cannot be reached at the numbers above.

Name of Emergency Contact(Required)

First Last

Phone of Emergency Contact(Required)

Medical Authorization(Required)

I understand that the Diocese of Springfield in Illinois assumes no responsibility for accidents which may occur in association with diocesan events and activities. I agree to use my/our personal insurance to cover any such incidents. I understand that, in the event medical intervention is needed, every attempt will be made to contact the persons listed above. In the event those individuals cannot be reached, I/We hereby give permission to the physician or any other qualified medical staff selected by the event leader to hospitalize, secure medical treatment, and/or order injection, anesthesia, or surgery for Participant as deemed necessary.

Yes

Release of Liability for Youth and Adults(Required)

I understand all reasonable safety precautions will be taken at all times by the Diocese of Springfield in Illinois and its employees and agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree to indemnify and hold harmless the Diocese of Springfield in Illinois and its leaders, employees and volunteer staff from any and all claims arising from or in connection with attending this event.

Yes

Code of Behavior for Youth and Adults(Required)

I agree to abide by and/or instruct my child to abide by all rules and regulations as outlined by the aforementioned chaperones/representatives. I agree that if I/Participant fail(s) to abide in any way by the rules, that I/Participant can be dismissed from the event and sent home immediately at my/Participant's expense with no right of reimbursement or refund for any amount in connection therewith from the Diocese of Springfield in Illinois or its chaperones/representatives.

Yes

Photo Release(Required)

I hereby authorize the Diocese of Springfield in Illinois and its agents to utilize photographic and/or video images of me or my child by the Diocese of Springfield in Illinois. In giving my consent, I hereby indemnify and hold harmless the Diocese of Springfield in Illinois and its agents from any and all responsibility of liability. I understand that I will receive no compensation should any photograph and/or video of me or my child be used.

Yes

Do you verify that you are the parent(s)/guardian(s) of the person(s) being registered?(Required)

Yes

eSignature(Required)

Date(Required)

MM slash DD slash YYYY