LEADER TEAM - Nov. 6-8, 2026 Reflections Confirmation Retreat Registration

LEADER TEAM - Nov. 6-8, 2026 Reflections Confirmation Retreat Registration

Select your registration type and complete the leader, emergency, and health details, then submit your $145 payment online.
Registration Type
What parish do you attend?
Leader Information
Name

First NameLast Name
Gender
Email
example@example.com
T-Shirt Size
Teen Leader Information
Grade
High School
Teen Team Member Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent Email
example@example.com
#1 Parent Name

First NameLast Name
#1 Parent Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
#2 Parent Name

First NameLast Name
#2 Parent Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Adult Leader Information
Adult / College Student
I will be helping with the following ministry
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
Emergency Contact Name (other than parents)

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Health Information
Medication: If medications (prescription and non-prescription) are needed, please send them with your child. List these medications in the following section and include product name and physician's instructions on dosage and frequency. Any medicine brought to retreat should be clearly labeled in their original container and checked in at registration. **Put 'NA' if this is Non-Applicable
Allergies, medical conditions, dietary needs, or other special needs (enter “NA” if not applicable)
Family Doctor
Doctor Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Health Plan Carrier
Policy Number
Retreat Payment

Cost is $145 per leader.

Reflections Confirmation Retreat – LeaderRegistration Nov 6th – 8th

$145.00

Mary, Queen of Peace Leader Registration

Do not pay here. You will pay your registration fee directly to MQP.

Free

Total

Debit or Credit Card
Credit Card Number	Security Code
Expiration Month	Expiration Year

Teen Leader Agreements
CODE OF CONDUCT- Student Portion:

I am willing and committed to follow all expected guidelines and rules for safety and consideration of others during the entire time that I am present on the confirmation Retreat. (THIS includes but is not limited to: going to bed at appointed time, no drugs or alcohol, proper attire and following directions of chaperones and leaders. I understand that my parent/guardian will be notified immediately of any infractions and that I will be sent home at the inconvenience of my parents if necessary.
**Student, draw your signature into the box below:
Student, please sign in the box below:
LIABILITY WAIVER

Please sign below to indicate you have read and agree to the terms of the following Liability Waiver:

I grant my son/daughter permission to participate in the REFLECTIONS Confirmation Retreat on Nov. 6-8, 2026

In consideration of the opportunity for my child to participate and fully recognizing that such an undertaking involves an element of risk, we assume all risks and hazards incidental in such participation and do hereby release, absolve, indemnify, and agree to hold harmless St. Susanna Parish, the Archdiocese of Indianapolis, its agents, employees and offices and the chaperones, leaders, organizers and sponsors, and persons. Neither the Archdiocese of Indianapolis/St. Susanna Parish nor any of said persons shall be held financially responsible for any injury, illness, or death incurred as a direct or indirect result of the activity. I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.

In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical treatment to be administered. I wish to be advised prior to any further treatment by the hospital or doctor.

We, the undersigned, have read this release and understand all its terms and execute it voluntarily and with full knowledge of the significance.
**Parent, draw your signature into the box below:
Parent, please sign in the box below:
Adult Leader Agreements
LIABILITY WAIVER

In consideration of the opportunity to participate and fully recognizing that such an undertaking involves an element of risk, we assume all risks and hazards incidental in such participation and do hereby release, absolve, indemnify, and agree to hold harmless St. Susanna Parish, the Archdiocese of Indianapolis, its agents, employees and offices and the chaperones, leaders, organizers and sponsors, and persons. Neither the Archdiocese of Indianapolis/St. Susanna Parish nor any of said persons shall be held financially responsible for any injury, illness, or death incurred as a direct or indirect result of the activity. I hereby warrant that to the best of my knowledge, I am in good health, and I assume all responsibility for my health.

I understand that I may be photographed, unidentified in group situations; and I hereby grant permission to be photographed for releases to the Criterion and/or Archdiocesan website, Parish bulletin boards, and/or other Parish promotions.

I, the undersigned, have read this release and understand all its terms and execute it voluntarily and with full knowledge of the significance.

Please draw your signature into the box below:
Please sign in the box below:
I agree to abide by the expectations for adult leaders. I have completed the new online training from Safe Parish (Starting Sept. 1, 2022 all adults must be trained and have a background check through this new system).

Draw your signature into the box below:
Please sign in the box below:
Should be Empty:

LEADER TEAM - Nov. 6-8, 2026 Reflections Confirmation Retreat Registration

Leader Information

Teen Leader Information

Adult Leader Information

Emergency Contact

Health Information

Retreat Payment

Cost is $145 per leader.*

Teen Leader Agreements

Adult Leader Agreements

Cost is $145 per leader.