Adjusted Kairos 52 Registration Form

CHILD INFORMATION:

Child's First Name REQUIRED Please fill out this field. Please enter valid data.

Child's Last Name REQUIRED Please fill out this field. Please enter valid data.

Address where child participant resides 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.

Child's Cell Number REQUIRED Please fill out this field. Please enter valid data.

Child's Email Address REQUIRED Please fill out this field. Please enter valid data.

Child's Date of Birth REQUIRED Please fill out this field. Please enter valid data.

Choose One REQUIRED Female Male Please fill out this field.

Child's High School REQUIRED Please fill out this field. Please enter valid data.

H.S. Graduation Year REQUIRED 2026 2027 Please fill out this field.

Child's Home Parish|Church REQUIRED Please fill out this field. Please enter valid data.

PARENT|GUARDIAN 1 INFORMATION:

Parent|Guardian 1 First Name REQUIRED Please fill out this field. Please enter valid data.

Parent|Guardian 1 Last Name REQUIRED Please fill out this field. Please enter valid data.

Parent|Guardian 1 Relationship to Child - Example: Mother, Father, etc. REQUIRED Please fill out this field. Please enter valid data.

Parent|Guardian 1 Cell Number REQUIRED Please fill out this field. Please enter valid data.

Parent|Guardian 1 Email Address REQUIRED Please fill out this field. Please enter an email address.

PARENT|GUARDIAN 2 INFORMATION:

Parent|Guardian 2 First Name REQUIRED Please fill out this field. Please enter valid data.

Parent|Guardian 2 Last Name REQUIRED Please fill out this field. Please enter valid data.

Parent|Guardian 2 Relationship to Child - Example: Mother, Father, etc. REQUIRED Please fill out this field. Please enter valid data.

Parent|Guardian 2 Cell Number REQUIRED Please fill out this field. Please enter valid data.

Parent|Guardian 2 Email Address REQUIRED Please fill out this field. Please enter valid data.

IN THE EVENT THE PARENT|GUARDIAN CAN'T BE REACHED, WHO SHALL WE 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.

Emergency Contact Phone Number REQUIRED Please fill out this field. Please enter valid data.

Relationship to Child: - Example: Grandfather, Grandmother, Neighbor etc. REQUIRED Please fill out this field. Please enter valid data.

CHILD PARTICIPANT HEALTH INFORMATION:

Child Participant Allergies and or Dietary Restrictions: NA or None if not applicable REQUIRED Please fill out this field. Please enter valid data.

Child Participant Current Medication[s]: NA or None if not applicable REQUIRED Please fill out this field. Please enter valid data.

Any Additional Information You'd Like Us to Know About Your Child Participant: NA or None if not applicable REQUIRED Please fill out this field. Please enter valid data.

Name of Child Participant Physician:

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Physician's Phone Number REQUIRED Please fill out this field. Please enter valid data.

Medical Insurance Policy in the Name Of:

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Medical Insurance Policy Number REQUIRED Please fill out this field. Please enter valid data.

Medical Insurance I.D. Number REQUIRED Please fill out this field. Please enter valid data.

PERMISSIONS:

Retreat Code of Conduct:
Rules of Behavior for Students:

Attend all scheduled activities
Will not smoke, vape or engage in the use of alcohol or drugs or have them in my possession.
Will treat all staff, chaperones and fellow participants with respect at all times
Will treat the facilities and grounds with respect at all times.
Will abide by any and all additional Rules expressed by the chaperones or facility staff.

Consequences of Not Abiding by the Rules:

For behavioral infractions or breaking of rules, warning will be given and the participant will have the opportunity to change the problematic behavior. If the problematic behavior continues, the participant will be asked to contact their parents to arrange to return home immediately.
If the participant uses alcohol or drugs during the event, even if they are not the one to bring them, they will be asked to contact their parent|guardian to arrange to return home immediately.

I Agree - Code of Conduct REQUIRED Parent|Guardian: Yes - I Agree - Code of Conduct Child Participant: Yes - I Agree Code of Conduct Please fill out this field.

As shown above, I have read and understand the Archdiocese of Chicago Permission Form and Participant Agreement, and I agree to abide by it. REQUIRED Parent|Guardian: Yes - I Agree - Archdiocese of Chicago Permission Form and Participant Agreement Child Participant - Yes - I Agree, - Archdiocese of Chicago Permission Form and Participant Agreement Please fill out this field.

I understand my child participant will be transported by bus to and from St. Benedict Retreat Center, Benet Lake, WI by Barrington Transportation Company REQUIRED Yes - I Agree - Transportation by Barrington Bus Company Please fill out this field.

I give permission for my child participant to receive email and text communication from Saint Anne Catholic Community, Barrington, IL Youth and Young Adult Ministry REQUIRED Yes - I Agree - Permission for child participant to receive email and text communication Please fill out this field.

Digital Signatures:

Parent|Guardian: Digital Signature (Please type name) REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED Please fill out this field. Please enter a date.

Child Participant: Digital Signature (Please type name) REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED Please fill out this field. Please enter a date.

K52 Adjusted: Enter Agreed Amount $ Please enter a positive decimal.

Would you like to help offset online payment processing fees? REQUIRED

3.2% for Credit Cards; 1.2% for ACH charges

Yes, I can help - Credit Card only Yes, I can help - ACH only No, thank you Please fill out this field.

Adjusted Kairos 52 Registration Form

Thank you for your interest in our Kairos 52 Retreat

Date: Nov 14-17, 2025

Cost: $425.00

Registration deadline: Oct 14, 2025 | No Refunds After Oct 14, 2025

Location: St. Benedict Retreat Center 12605 224th Ave., Benet Lake, WI

Required Read:
Archdiocese of Chicago
Permission & Agreement

Adjusted Registration Form: