St. Patrick Upperclassman Retreat

Complete this form to register for our Upperclassman Retreat. The Retreat will take place December 19-20.

Retreat Details:

Retreat Starts:	Friday, December 19 at 5:00 PM
Retreat Ends:	Saturday, December 20 at 10:00 AM
Location:	St. Patrick Parish
Cost:	$15.00 (Covers Dinner, Snacks, and Breakfast)

Retreat activities will include: a talk, and Eucharistic Adoration. Breakfast, Dinner, and Snacks throughout.

Student and Parent Information:
Student Name*

First NameLast Name
Gender:*

MaleFemale
Student Email Address*
example@example.com
Parent Contact Name:*

First NameLast Name
Parent E-mail Address:*
Parent Phone Number*
Medical Form and Release
Please indicate any allergies, medications, special needs, or physical/mental health conditions that we should know about in the fields below. You may leave any fields blank that do not apply to your child:
Dietary Restrictions or Food Allergies
e.g., vegan, gluten free, peanut allergy
Other Allergies:
Medications your child takes:
Medical conditions:
e.g., asthma, type 1 Diabetes, epilepsy
Mental or behavioral health conditions:
e.g., anxiety, bipolar disorder, ADHD
Any special needs (physical, learning, or behavioral) that we should be prepared to accommodate:
Emergency Contact: In case of emergency, we will make multiple attempts to reach the parent listed on this registration form. However, in case we are unable to reach you in an emergency situation, please provide an alternative person and phone number that we can contact.
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Relation to Child*
Emergency Contact Phone Number
Medical Release*

Parental Consent to Participate

Your son/daughter is eligible to participate in a parish sponsored activity. This activity will take place under the guidance and supervision of authorized personnel from St. Patrick Catholic Parish. A brief description of the activity is found below.

	Name of Event:	O Come Let Us Adore Him Upperclassman Retreat
	Date of Event:	December 19-20 2025
	Location:	711 Rickett Road
	Designated Supervisor of Event:	Samuel Ekblad

If you would like your child to participate in this event, please sign the following statement of consent and acknowledgment. As parent or legal guardian, you remain responsible for any legal responsibility which may result from actions taken by the named student.

Permission to participate.*
Photo Release
Parent Signature*

Clear
Type Parent Name here:*

Retreat Payment

The cost of this retreat is $15. This covers the cost of meals and activities.

Please make your payment selections below:

Upperclassman Retreat Fee

$15.00

Enter coupon

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Questions/Comments Regarding Payment:
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St. Patrick Upperclassman Retreat

Retreat Details:

Student and Parent Information:

Medical Form and Release

Parental Consent to Participate

Retreat Payment

Payment Methods