Evanston & Skokie Kairos Interest Form
Friday, August 16-Monday, August 19
Loyola Retreat & Ecology Campus
James Holzhauer-Chuckas, ObSB
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
Teen First & Last Name
Teen Cell Phone
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)
What parish or religious organization are you from?
St. Athanasius Parish
St. Joan of Arc Parish
St. Mary Parish
St. Nicholas Parish
St. Peter Parish
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.
Parent/Guardian 1 First & Last Name
Parent/Guardian 1 Cell Phone
Parent/Guardian 2 First & Last Name
Parent/Guardian 2 Email 2
Parent/Guardian 2 Cell Phone
Emergency Contact Information (Please list first and last name, phone number, and relation to teen)
The total cost of the retreat is $300 (including the deposit). Will you need financial assistance and/or a payment plan?
I do not need financial assistance or a payment plan
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.
We will contact you with more information and with further instructions.
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