Kairos Retreat Registration

Please complete the entire form.

The retreat runs from Thursday after school until about 2:00 on Sunday. Please do not make
plans for anything else during that time. Students cannot join the retreat late or leave and return
to attend other events.

Email address *
Which retreat are you registering for? *
Student Name (First and Last) *
Your answer
Gender *
Grade Level *
Home Address: (including City and Zip Code) *
Your answer
Home Phone Number: *
Your answer
Mother's Name (First and Last) *
Your answer
Mother's Cell Phone: *
Your answer
Mother's Email Address *
Your answer
Father's Name *
Your answer
Father's Cell Phone *
Your answer
Home Parish *
Your answer
Doctor Name *
Your answer
Doctor Phone Number *
Your answer
Please list any allergies or dietary requirements of which we need to notify the kitchen staff (vegetarian, peanut allergies, gluten intolerance, etc.). It is important that we know about these things ahead of time. *
Your answer
Because of the length of the program (three full days), it is necessary to charge $150.00 to help
cover the costs. No student will be turned down because of money! See Celina Poppe in the Campus
Ministry Office for more information. FULL PAYMENT IS DUE AS SOON AS POSSIBLE. Payment
can be sent to the Business Office.
Individual in Charge:
Mrs. Celina Poppe and Ms. Catherine Coffey
Estimated time of departure and return:
3:30 pm Thursday to 2:00 pm Sunday
Mode of transportation to and from event:
School Bus
Cost to be paid by student:
$150 (Please make checks out to Judge Memorial High School)
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