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Kairos 53 Adult Leader Form

- Adult Leader Form and Waiver
  Date: Feb 13-16, 2026
  Location: Bishop Lane Retreat Center 7708 E. McGregor Rd., Rockford, IL
  Questions? Contact Amy Hodson at [email protected] or 847-620-3073 for more information.
- Required Read:
  Archdiocese of Chicago
  Permission & Agreement
- Adult Leader Form:
  
  This form is not accepting responses at this time.
  
  ADULT LEADER INFORMATION:
  
  Adult Leader First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Adult Leader Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Address where adult leader 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.
  
  Adult Leader Email Address REQUIRED Please fill out this field. Please enter an email address.
  
  Adult Leader Cell Number REQUIRED Please fill out this field. Please enter valid data.
  
  Adult Leader Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Choose One REQUIRED Please fill out this field.
  
  Emergency Contact Information
  
  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 Adult Leader: - Example: Spouse, Parent, Neighbor REQUIRED Please fill out this field. Please enter valid data.
  
  ADULT LEADER HEALTH INFORMATION:
  
  Adult Leader Allergies and or Dietary Restrictions: NA or None if not applicable REQUIRED Please fill out this field. Please enter valid data.
  
  Adult Leader 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: NA or None if not applicable REQUIRED Please fill out this field. Please enter valid data.
  
  Name of Adult Leader 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 Participant:
  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 leave 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 leave immediately.
  
  I Agree - Code of Conduct REQUIRED Adult Leader: 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 Adult Leader: Yes - I Agree - Archdiocese of Chicago Permission Form and Participant Agreement Please fill out this field.
  
  I understand I may be transported by bus to and from the retreat center by Barrington Transportation Company REQUIRED Yes - I Agree - Transportation by Barrington Bus Company Please fill out this field.
  
  I give permission to receive email and text communication from Saint Anne Catholic Community, Barrington, IL Youth and Young Adult Ministry REQUIRED Yes - I Agree - Permission to receive email and text communication Please fill out this field.
  
  Digital Signatures:
  
  Adult Leader: Digital Signature (Please type first and last name) REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  Submit
  
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Kairos 53 Adult Leader Form

Date: Feb 13-16, 2026

Location: Bishop Lane Retreat Center 7708 E. McGregor Rd., Rockford, IL