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CRUX Teen Retreat Registration

- Teen Registration/Permission Form
  
  The maximum number of form submissions has been reached. This form is currently not available.
  
  This form and payment of the $240 fee must be completed on or before February 3, 2023. Your prompt registration is appreciated and important. Athough the deadlines is February 3, this events sells out and registration could close earlier. Registrations are processed in order of receipt. Ifyou have payment problems, please contact Helen at [email protected]. Any cancellation within one week of departure is non-refundable.
  
  Please address any questions about registration to [email protected]
  
  Teen First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Teen Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Nickname for name badge Please enter valid data.
  
  Year in School REQUIRED Soph Junior Senior Please fill out this field.
  
  Are you a member of the retreat planning team? REQUIRED Yes No Please fill out this field.
  
  Teen Cell REQUIRED Please fill out this field. Please enter valid data.
  
  Teen Email REQUIRED Please fill out this field. Please enter valid data.
  
  Street Address 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.
  
  Parent/Guardian Name REQUIRED Please fill out this field. Please enter valid data.
  
  Parent/Guardian Cell Phone REQUIRED Please fill out this field. Please enter valid data.
  
  Parent/Guardian Email REQUIRED Please fill out this field. Please enter an email address.
  
  Roommate preference. List 3 maximum. We will do all possible to accommodate your request. There will be 4 people per room.
  
  Emergency Information
  
  Medical Insurance Company REQUIRED Please fill out this field. Please enter valid data.
  
  Insurance Policy Number REQUIRED Please fill out this field. Please enter valid data.
  
  Name of Physician REQUIRED Please fill out this field. Please enter valid data.
  
  Physician Address: REQUIRED Please fill out this field. Please enter valid data.
  
  Physician Phone: REQUIRED Please fill out this field. Please enter valid data.
  
  Please list any allergies, medications, medical problems, significant medical history, physical activities/limitations that your teen CANNOT take part in.
  
  Adult Volunteer Opportunity:
  
  There are at least 8volunteers needed to ensure the safety of the teens. Please indicate if you are willing to work any of the following times:
  
  I am available Saturday night 10:30 p.m. - 12:30 a.m. Saturday overnight 10:30 p.m. - Sunday morning 8:00 a.m.
  
  Consent Agreement
  
  I hereby give permission for my teen to participate in the MSW Crux Overnight Teen Retreat weekend at the Hyatt Regency O'Hare Chicago, 9300 Bryn Mawr Avenue, Rosemont, IL, 60018, on March 11 and March 12, 2023. I hereby release and indemnify Mary, Seat of Wisdom Parish, its staff and volunteers and the Catholic Bishops of Chicago, a corporation sole, from any and all liability arising from claims of any kind of nature whatsoever, from my child’s participation in this event. I understand that my child’s personal belongings are open for inspection by adult chaperones and if alcohol, drugs or tobacco are discovered OR consumed, I will be contacted and my teen may be asked to leave the retreat. In the event that the undersigned cannot be reached, and in the judgment of the responsible adults or other appropriate staff member accompanying the group, there is a necessity for immediate examination and/or treatment of my child, I hereby authorize any of the aforesaid personnel to obtain for my child such medical services as are deemed necessary.
  
  I Agree (Teen) - Checking this box serves as a digital signature to the consent form Please select this field.
  
  I Agree (Adult) - Checking this box serves as a digital signature to the consent form Please select this field.
  
  Teen Registration Fee240.0
  
  I would like to include an additional donation to the Scholarship Fund to help cover the cost for those who may find it financially difficult to attend $ Please enter a positive decimal.
  
  Total:
  
  Submit
  
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CRUX Teen Retreat Registration

Emergency Information

Adult Volunteer Opportunity: