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10/21-22 MS Retreat

- RELIGIOUS/FAITH EDUCATION

DOLC Youth 10/21-22 MS Retreat
DOLC Youth KING of Kings MS Retreat registration
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- STUDENT INFORMATION:
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Student Age REQUIRED Please fill out this field. Please enter an integer (number).
- Student Grade REQUIRED Please fill out this field. Please enter an integer (number).
- Student Gender REQUIRED Female Male Please fill out this field.
- Name of Church (where student attends Mass.) REQUIRED Please fill out this field. Please enter valid data.
- PARENT INFORMATION:
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Relationship to Student (Mother, Father, Grandparent) REQUIRED Please fill out this field. Please enter valid data.
- Parent Mobile Phone Number (for notifications) REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Parent Email REQUIRED Please fill out this field. Please enter an email address.
- Medical: 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 my permission to transport my child to a hospital for emergency or surgical treatment. I wish to be advised prior to any futher treatment by the hospital or doctor.
  
  I will be given the opportunity to agree or disagree below. If I disagree, I will contact the Diocese of Lake Charles, Office of Youth Ministry immediately.
- I agree to the medical statement for emergency treatment listed above. REQUIRED YES NO Please fill out this field.
- EMERGENCY CONTACT INFORMATION: In the event of an emergency if you are unable to reach me at the above numbers, contact:
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Phone # 2 REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Family Health Plan Carrier REQUIRED Please fill out this field. Please enter valid data.
- Policy Number REQUIRED Please fill out this field. Please enter valid data.
- Doctor Name REQUIRED Please fill out this field. Please enter valid data.
- Doctor Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Payment Options REQUIRED Pay Online Now. Pay later by cash or check. Please fill out this field.
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Immaculate Conception

Catholic Church

10/21-22 MS Retreat

DOLC Youth 10/21-22 MS Retreat

DOLC Youth KING of Kings MS Retreat registration