"Listen Closely" Retreat registration form

“Listen Closely” Retreat
For 17 (and have graduated gr. 12), to 19 year olds
January 3 rd to January 4 th , 2013
Holy Family Parish
St George Parish
c/o Patty Coenen
c/o Michele Schaeken
777 Valetta Street 1164 Commissioner Road West
London, ON
London, ON
N6H 2Y9
N6K 1C7
Total Cost: $60.00 (includes “Retreat” day activities, sleepover at “Michaelite Retreat House”, snacks, and meals).
*****If you register BEFORE Sunday, December 9 th , then registration fee is only $50.00 *****
Please make cheques payable to “Holy Family Parish”
PARTICIPANT INFORMATION
First Name:
Address:
Last Name:
City: Postal Code: Phone:
Youth’s Email Address:
Parent’s Email Address:
Health Card Number:
MEDICAL INFORMATION
Mother’s Name:
Father’s Name:
Emergency Contact:
Date of Birth:
Allergies/Medical Concerns:
Doctor’s name:
Phone:
Phone:
Phone:
Release of Liability
I give permission for my above named son/daughter/dependant to attend the retreat “Listen Closely” on Thursday, January 3 rd to
Friday, January 4 th , 2013 at The Michaelite Retreat House in London.
If needed for health reasons, I give permission for my child to be evaluated, diagnosed, treated and/or given medication in
accordance with standard medical practice by licensed medical personnel. I relieve Holy Family Parish/St George Parish; its
employees and volunteers of all responsibility and consequences that may arise as a result of this treatment. I will not hold the
event organizers Holy Family Parish/St George Parish, its employees and/or its volunteers liable in the event of injury. Further, I
agree to accept any and all financial responsibilities as a result of scheduling medical treatment.
My child agrees to abide by all the rules and regulations stated by the event organizers and by the hosting group. I understand that
Holy Family Parish/St. George Parish will not be held liable if my child fails to cooperate with the regulations and that any
infraction of the rules may result in immediate dismissal from the event at my expense. I will not hold the Parishes, its volunteers
or the conference liable for any missing personal items.
Signature: _____________________________________________________
(From Parent/Guardian if under 18)
Date: ________________________________
Media/Picture Release
Photographs and videos taken at the “Listen Closely” retreat may be used in future advertisement of the event or youth events. If
included, participants will not be identified by name.
I Accept
I Decline
Signature: ______________________________________________
(From Parent/Guardian if under 18)
Any Questions please contact:
• Patty Coenen @ 519-472-0057 ext. 258 or by email at pcoenen@dol.ca
• Michele Schaeken @ 519-471-4220 ext. 13 or by email: mschaeken@dol.ca
Date: _____________________________

Holy Family Parish and St. George Parish have
teamed up together to run a retreat for young
people who have graduated grade twelve and are
younger than 20 years old. The “Listen Closely”
prayer retreat starts Thursday, January 3 rd at 1pm
and ends Friday January 4 th at 5pm. We will be
sleeping at the Michaelite Retreat house.
Food will be provided.
Please register early.
Space is limited !
Packing List
Warm Pajamas
Change of Clothes – modest and for the weather
Winter clothes for when we go outside to make SNOW ANGELS and have FUN.
Refillable water bottle
Toiletries (toothbrush, toothpaste, soap, hairbrush etc. – remember we are sleeping over night)
Washcloth and towel
“Listen Closely” retreat will be held at the beautiful “Michaelite House Retreat Centre” located at 2751
Sunningdale Road West, London, ON N6H 5L2. (between Denfield Road and Vanneck Road)
From London: Take north any major streets of London until you get to Sunningdale Road and turn
left/West, past Hyde Park Road. Go almost to the very end and turn left at the sign ‘Michaelite Fathers’.
They are located at the end of the driveway.