High School Retreat | St. Mary Catholic Church | Delaware, OH

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RETREAT
REGISTRATION

HIGH SCHOOL RETREAT REGISTRATION

February 28-March 1. Cost $100.00/person. Scholarships are available. Contact meverhart@delawarestmary.org

Registered in Parish *

YES

NO

I acknowledge that this adult has permission to pick up my child from The Retreat

I acknowledge that this adult has permission to pick up my child from The Retreat.

Child Registration

PHOTO RELEASE AND WAIVER

I give my permission for the above mentioned photographs, which may include my child, to be used in Parish publications, promotional pieces, and/or the parish website and related social media. *

YES

NO

MEDICAL INFORMATION AND AUTHORIZATION

In case of emergency, I understand St. Mary will make every effort to contact me. However, if they cannot reach me, I give my permission to take my child for emergency treatment. I release St. Mary staff and volunteers from all liability of any kind which may arise from such an emergency.

Medical Needs (Check All Applicable)

Gluten

Peanut

Dairy

Treenut

Egg

Seasonal

Bee Stings

Asthma

Educational Needs (Check All Applicable)

ADD

ADHD

Autism

Behavioral disturbance

Emotional disturbance

Hearing impairment (including deafness)

Visual impairment (including blindness)

Orthopedic (unable to use stairs)

Speech or language impairment

Child needs individual aid in class

Developmental disabilities

Learning disabilities

Reading difficulties

Traumatic brain injury

EMERGENCY CONTACTS & TRANSPORTATION

I acknowledge that these adults have permission to pick up my child from The Retreat and that no other adult may do so unless they are listed here.

I acknowledge that this adult has permission to pick up my child from The Retreat

I acknowledge that this adult has permission to pick up my child from The Retreat

Parent or Guardian Signature

ABOUT ST. MARY

ADDRESS

Under the patronage of Our Blessed Mother, and rooted in the Roman Catholic faith since 1835, St. Mary Delaware is a vital and vibrant community that engages the living God in worship and prayer, and in Word and Sacrament. Led by the Holy Spirit, and imploring the intercession of St. Mary, we desire to imitate her role of being the Christ bearer, and bear witness to her Son’s redeeming love that has been poured upon us in Baptism, and sustained by the practices and teachings of the Church.

740.363.4641 (p)

740.363.9915 (f)

82 E. William Street

Delaware, Ohio 43015

stmary@delawarestmary.org

© 2019 by JP Signs & hellomackeymedia | JMJ | Copyright St. Mary Catholic Church, Delaware, Ohio

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