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Kairos 55 Teen Leader Permission Form

- Teen Leader Permission Form and Waiver
  Date: Feb 12-17, 2027
  Cost: $200.00
  Registration deadline: Jan 12, 2027 | No Refunds After Jan 12, 2027
  Location: Bishop Lane Retreat Center 7708 E McGregor Rd., Rockford, IL
  
  This online registration is payable by Credit Card and ACH payment only. If you choose to register and pay offline, please contact the Youth and Young Adult Ministry office at [email protected] for registration and payment forms.
  
  Questions? Contact Amy Hodson at [email protected] or 847-620-3073 for more information.
- Required Read:
  Archdiocese of Chicago
  Permission & Agreement
- Teen Leader Permission Form:
  
  This form is not accepting responses at this time.
  
  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 (included dashes) 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 Please fill out this field.
  
  Child's High School REQUIRED Please fill out this field. Please enter valid data.
  
  H.S. Graduation Year REQUIRED Please fill out this field.
  
  Child's Home Parish|Church REQUIRED Please fill out this field. Please enter valid data.
  
  T-Shirt Size REQUIRED Please fill out this field.
  
  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 (include dashes) 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 (include dashes) 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?
  
  Emergency Contact First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Phone Number (include dashes) 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:
  
  Physician First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Physician Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Physician's Phone Number (include dashes) 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 will be responsible for their own transportation to and from the retreat center. REQUIRED Yes - I Agree - My child is responsible for their own transportation. 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 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.
  
  Child Participant: 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.
  
  Kairos 55 Teen Leader Fee200.0
  
  Would you like to help offset online payment processing fees? REQUIRED
  3.00% for Credit Cards; 1.0% for ACH charges
  Yes, I can help - Credit Card only Yes, I can help - ACH only No, I do not wish to offset the online processing fee Please fill out this field.
  
  Total:
  
  Submit
  
  Proceed to Payment

Kairos 55 Teen Leader Permission Form

Date: Feb 12-17, 2027

Cost: $200.00

Registration deadline: Jan 12, 2027 | No Refunds After Jan 12, 2027

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