Camp Karol

Lake Charles, LA

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Silent Retreats

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Registration form for October 5, 2024 High School Day of Silent Reflection
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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.
- Street Address 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.
- Teen's Contact Number Maximum 20 characters Please enter a phone number.
- Teen's Email REQUIRED Please fill out this field. Please enter an email address.
- Gender REQUIRED Female Male Please fill out this field.
- Current Grade Level REQUIRED 9th grade 10th grade 11th grade 12th grade Chaperone Please fill out this field.
- Retreatant Age REQUIRED Please fill out this field. Please enter valid data.
- Church Parish Please enter valid data.
- Best Parent or Guardian Contact
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Parent/Guardian Email REQUIRED Please fill out this field. Please enter an email address.
  
  Parent/Guardian Phone #1 REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Parent/Guardian Phone #2 Maximum 20 characters Please enter a phone number.
  
  MEDICAL:
  I hearby warrant, to the best of my knowledge, my child 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.
  
  Emergency Contact:
  
  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 Maximum 20 characters Please fill out this field. 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.
  
  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.
  
  Please list ANY and ALL FOOD ALLERGIES your child suffers from that we need to be aware of when preparing meals for this retreat.
  
  The cost of attending this Day of Silence is $30 per person. If you prefer to pay early, then payment can be sent to St. Charles Center's Office:
  
  2151 Sam Houston Jones Pkwy.
  Moss Bluff, LA 70611
  
  If paying by check, please make the check payable to Camp Karol. There will be a check-in station at Camp Karol the day of where payment can also be received.
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Silent Retreats

Photograph & Video Consent: