Kairos 47 Registration

Personal Information

Teen First Name *

Teen Last Name *

Nickname

Gender *

Birthday *Birthday

Month

Day

Year

School *

Name of School (if Other)

Year in School *

Church/Faith Community *

Name of Other Church/Faith Community

T-Shirt Size *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal code *

Teen Email Address *

Teen Phone Number *

Parent/Guardian Information

Parent/Guardian 1 First Name *

Parent/Guardian 1 Last Name *

Parent/Guardian 1 Cell Phone *

Parent/Guardian 1 Email Address *

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Parent/Guardian 2 Cell Phone

Parent/Guardian 2 Email Address

Check all guidelines to signify that you meet the guidelines and will adhere to the expectations *I am a junior or senior in high school.I will participate in all group activities.I will respect the property we will be using, as well as the property of others.I will not leave the facility during the retreat.I will not bring illegal substances or electronic devices (phones, devices, games).Alcoholic beverage/drugs of any kind/sex are not allowed, and will not be tolerated.By entering my name below I confirm agreement with the preceding terms.

Teen Name *

Today's Date *

Applicant Questionaire

How did you hear about Kairos *

Please explain briefly why you want to attend the Kairos retreat. *

Parent Guardian Affidavit and Authorization

I give permission for my teen to attend the Kairos retreat sponsored by St. John of the Cross Parish, during the dates of November 12-15, 2026. I am aware that my teen will travel by bus and stay at St. Mary’s Retreat House, 14230 Main St. Lemont, IL 60439

I hereby release and indemnify St. Mary’s Retreat House, its staff, the staff and volunteers of St. John of the Cross Parish, a corporation sole, from any and all liability arising from claims of any kind or nature whatsoever from my child’s participation in this program. If I, my spouse, or our authorized physician cannot be reached, and in the judgment of the adult leaders, if there is a necessity for immediate examination and/or treatment of my child, I hereby authorize any of the aforesaid personnel to obtain for my child such medical services as are deemed necessary.

I understand that I will be called and asked to pick up my child immediately if he/she does not abide by the rules of the weekend as stated above.

Parent Name *

Date *

Physician Name *

Physician Phone *Physician Phone

Medical Insurance Company *

Policy/Group Number *

Please list any and all of your child's medical conditions, medications, or dietary needs *

Registration Fee *If registering multiple people, please submit an additional registration form.1 Participant

Calculations

$

Credit / Debit Card *

Kairos Registration

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