ANTIOCH 73 CANDIDATE APPLICATION
• When is the weekend? From 7:00pm, Friday, December 15, 2017 thru 6 PM, Sunday, December 17, 2017
• Where is the weekend? Notre Dame of Mount Carmel Church (see address above).
• Who can come? 10th through 12th grade high school students
• What is the registration fee? $40.00. Payable by credit card only on the parish website.
• What will I need to bring? Comfortable, informal clothing (no tank tops, no shorts shorter than the length of fingertips above the knees), sleeping bag, bath towel and toiletries, and donations of two cases of 24, 8oz-bottled water would be greatly appreciated (water can be dropped off at the kitchen when you arrive Friday night).
• Who can I contact if I have any questions? Caitlin Coriddi at caitlincoriddi@gmail.com.

SPACE WILL NOT BE RESERVED UNLESS APPLICATION & FEE ARE COMPLETED ONLINE BY NOVEMBER 19, 2017.

TEEN INFORMATION
First Name *
Your answer
Last Name *
Your answer
Birthdate *
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Age *
Your answer
Gender: *
Home Phone No. *
Your answer
Address (Street) *
Your answer
Town *
Your answer
ZIP *
Your answer
Current Grade *
Your answer
High School You Attend *
Your answer
Teen Cell No. *
Your answer
Teen E-mail *
Your answer
Your Parish *
Your answer
List any medical issues, allergies, and/or medications you are currently taking: *
If none, please indicate "None"
Your answer
Special Dietary Needs or Restrictions *
If none, please indicate "None"
Your answer
Family Physician: *
Your answer
Physician Phone No. *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact - Best Phone # to reach *
Your answer
Who or what helped you decide to come to Antioch? *
Your answer
What are your interests or activities in which you participate? *
Your answer
How many Antioch retreats have you made (including other parishes)? *
Your answer
When was your last one? *
If this will be your first Antioch, please enter "First one"
Your answer
Where did you make your last Antioch weekend? *
If this will be your first Antioch, enter N/A.
Your answer
PARENTS CONTACT INFORMATION
Father's Name: *
Your answer
Father's Cell No. *
Your answer
Father's Email: *
Your answer
Mother's Name: *
Your answer
Mother's Cell No. *
Your answer
Mother's Email: *
Your answer
PARENTAL PERMISSION & ELECTRONIC SIGNATURE REQUIRED FOR TEENS UNDER 18!
Dear Parent/Guardian, please complete this part of the application. Thank you!
I give full permission for my child to participate in the Antioch weekend at Notre Dame of Mt. Carmel Church, from Dec. 15 - Dec 17, 2017. I understand that this event is being carefully and professionally planned. I am aware that the teenagers will be sleeping under adult supervision in assigned sleep groups separated according to gender at Notre Dame of Mount Carmel Church. I certify that all of the above information is current, accurate, and truthful. I can be reached at the above telephone numbers during the Antioch weekend. If emergency care or treatment is necessary and I cannot be reached, I authorize the delegated agents of Notre Dame of Mount Carmel Church to contact appropriate emergency medical personnel and provide any relevant medication information. I also fully expect to be notified if my child is disrespectful or uncooperative. I understand that there is a zero tolerance policy and that I will be notified after the first violation of a rule and that my child may be sent home. In addition, I hereby agree to forfeit any and all claims against the Parish, the Bishop, the Diocese of Paterson, and its agents, servants, volunteers, and employees from any and all liability, loss, cost, expense or damage, including suits, claims, and demands of every kind and nature, including punitive damages, arising out of or based upon any accident, injury, or damage, however occurring, which may happen on or off the Notre Dame Parish premises, which in any way relates to or arises from the candidate’s participation in such activity. By signing this form, I am committing my child to participate in the ENTIRE Antioch weekend. I understand that exceptions will not be made for anyone to leave anytime during the retreat or before the closing mass. *
Required
I hereby enter my name below as electronic signature/official approval of my child's participation in the retreat. *
Your answer
IMPORTANT: Once you submit this form you will be given a link to access the ONLINE PAYMENT link where you may process your payment via Credit Card.
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