Candidate Application
Email address *
Personal Information
First Name *
Your answer
Last Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Date of Birth *
Your answer
Sex *
Age *
How old will you be at the time of the retreat?
Your answer
School *
Your answer
Grade *
What grade will you be in at the time of the retreat?
Your answer
Parish *
Your answer
Which weekend are you applying for? *
Mother's Name
Your answer
Mother's Work Phone Number
Your answer
Mother's eMail Address
Your answer
Father's Name
Your answer
Father's Work Phone Number
Your answer
Father's eMail Address
Your answer
Have you ever been on a weekend retreat before? *
If Yes, which ones?
Your answer
List and Church or School activites that you are a part of: *
Your answer
List your hobbies, interest and talents: *
Your answer
What is the name of your Journey sponsor? *
Your answer
Has your sponsor answered any questions that you may have? *
Are you aware that the weekend starts on Thursday evening at 6:30 PM? *
Are you aware that the weekend ends on Sunday evening? *
Why would you like to attend a Journey weekend? *
Your answer
What do you hope to gain by attending a Journey weekend? *
Your answer
Medical Information
Allergies *
Environmental & Medications
Your answer
Required Medications *
Include Dosages, Frequencies and Time of Day to be taken
Your answer
Special Medical Conditions *
Your answer
Special Dietary Considerations and/or Restrictions *
Your answer
Date of last Tetnus booster *
Your answer
Insurance Information
Insurance Company Name *
Your answer
Policy/Group Number *
Your answer
Name of Policy Holder *
Your answer
Contact In Case of an Emergency
Name *
Your answer
Home Phone *
Your answer
Work Phone *
Your answer
Cell Phone *
Your answer
Backup Contacts In Case of an Emergency
Primary Backup Name *
Your answer
Primary Backup Phone Number *
Please let us know if this is a cell phone
Your answer
Secondary Backup Name
Your answer
Secondary Backup Name
Please let us know if this is a cell phone
Your answer
Please send your payment of $200.00 to:
ST. KATERI TEKAKWITHA PARISH
ATTN: JOURNEY RETREAT
2216 Rosa Road, Schenectady, NY 12309
Please make check payable to the St. Kateri Parish - Journey Retreat
A copy of your responses will be emailed to the address you provided.
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