Evanston & Skokie Kairos Interest Form
Retreat Info:
Friday, August 16-Monday, August 19
Loyola Retreat & Ecology Campus

Retreat Director:
James Holzhauer-Chuckas, ObSB
847-864-1185 x26
jholzhauer-chuckas@nickchurch.org

READ THIS FIRST:
If you are applying as a leader, please DO NOT fill out this form! This form is only for the retreat participants. To apply to be a leaders, please send an email to James Holzhauer-Chuckas, ObSB at jholzhauer-chuckas@nickchurch.org
Teen First & Last Name *
Your answer
Teen Email *
Your answer
Teen Cell Phone *
Your answer
Year in School (2019-20 Year) *
What school do you attend? (Please put N/A if you are college-age and are not currently enrolled in school) *
Your answer
What parish or religious organization are you from? *
PARENT(S)/GUARDIAN(S) PLEASE NOTE:
Email will be a crucial method of contact, please verify that the email address(es) you enter are correct before submitting the form.
Home Address *
Your answer
Parent/Guardian 1 First & Last Name *
Your answer
Parent/Guardian Email *
Your answer
Parent/Guardian 1 Cell Phone *
Your answer
Parent/Guardian 2 First & Last Name
Your answer
Parent/Guardian 2 Email 2
Your answer
Parent/Guardian 2 Cell Phone
Your answer
Emergency Contact Information (Please list first and last name, phone number, and relation to teen) *
Your answer
The total cost of the retreat is $300 (including the deposit). Will you need financial assistance and/or a payment plan? *
Required
I understand that a deposit of $50 to secure a spot is due at the time of registration. Please make checks to "St. Nicholas Parish" with "Kairos" in the memo line. *
Thank You!
We will contact you with more information and with further instructions.
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