Camp Karol

Lake Charles, LA

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Middle School Retreat Registration

- Retreats and Programs

MIDDLE SCHOOL RETREAT (APRIL 11-13, 2025) REGISTRATION FORM
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- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Church Parish REQUIRED Please fill out this field. Please enter valid data.
- Email Address (best for contact): REQUIRED Please fill out this field. Please enter an email address.
- Gender: REQUIRED Please fill out this field.
- Age Range REQUIRED Please fill out this field.
- Best Parent or Guardian Contact
  
  Parent/Guardian Name: REQUIRED Please fill out this field. Please enter valid data.
  
  Best Parent/Guardian Email REQUIRED Please fill out this field. Please enter an email address.
  
  Parent/Guardian Phone Number #1 REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Parent Guardian Phone Number #2 Maximum 20 characters Please enter a phone number.
  
  Medical Information:
  
  MEDICAL: I hereby warrant that to the best of my knowledge, my child or myself (if form is for the person filling it out) is in good health and I assume all responsibility for the health of my child. In the event of an emergency I hereby give my permission to transport my child to a hospital for emergency or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor and if the medical needs are for me please notify my emergency contact.
  
  In the event of an emergency if you are unable to reach me at the above numbers, contact:
  
  Emergency Contact Person: REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Primary Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Emergency Contact Secondary Phone Number Maximum 20 characters Please enter a phone number.
  
  Policy and/or Group Number REQUIRED Please fill out this field. Please enter valid data.
  
  Family Health Plan/Carrier REQUIRED Please fill out this field. Please enter valid data.
  
  Note: All medications will be turned in at registration and distributed by our Med Staff. Medical Form
  
  Any Food Allergies? Type 'NONE' if the registering retreatant has no allergies. REQUIRED Please fill out this field.
- CONTRACT OF BEHAVIOR:
  
  As a participant at this event, I will…
  Take care of the property of the facility being used. I understand I will need to pay for any accidental damage to property.
  Show respect to all people – participants, adults, speakers, and diocesan staff.
  Maintain a healthy environment – no mood altering drugs, including alcohol, is to be used by anyone including adults. Prudent precaution will be taken to assure that no one has any mood altering drugs in their possession. Possession of alcohol is grounds for dismissal from the retreat. We provide a smoke-free environment. NO VAPING!
  Maintain a moral atmosphere – At all times dress, music, dance, language, signs of affection, tone of voice is to be appropriate.
  
  I have read the above responsibilities of participants and as a participant will follow the code of conduct.
- Signature: REQUIRED Please fill out this field. Please enter valid data.
- Parent Signature: REQUIRED Please fill out this field. Please enter valid data.
- ATTENTION: Failure to abide by the Contract of Behavior hereby signed will result in dismissal from retreat with NO REFUND.
- PHOTOGRAPH & VIDEO CONSENT:
  From time to time, photographs and/or video may be taken of youth ministry events and gatherings. We would like to be able to use these photographs and videos for flyers, parish and diocesan publications, social media, and the ministry website. Names will not be posted unless written consent is obtained from the student and parent/guardian, and then only first names will be used. If there is concern about photographs or videos posted on the website, please contact the ministry coordinator and they will be promptly removed.
- I hereby agree/disagree to the Photography and Video Consent Policy REQUIRED I agree I disagree Please fill out this field.
- COST AND PAYMENT DETAILS:
  
  The cost for the overnight Middle School Retreat is $185 per child.
  
  For payment, make checks payable to: Camp Karol.
  
  Send all payments to St Charles Center:
  
  2151 Sam Houston Jones Pkwy
  Moss Bluff, LA 70611
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Middle School Retreat Registration

PHOTOGRAPH & VIDEO CONSENT: