Our Lady of Perpetual Help Catholic Church – Selma, TX
TEEN ACTS Retreat Registration Form
July 25 – 28, 2013
Participant’s Name: _____________________________________________
Age: _______
Birth Date: ____________________ Grade: _______
Gender:
M
F
Shirt Size: Sm Med Lg XLg XXLg
School: _____________________________________________________
Parish: ________________________________________
Home address: _______________________________________________
City: ________________________Zip: ______________
Home telephone: ______________________________________________
Youth Cell: _____________________________________
Parent/Guardian’s Name: __________________________________________________________________________________________
Home address: ________________________________________________
City: _________________________ Zip: ______________
Home telephone: ______________________________________________
Business phone: __________________________________
Parent Cell phone: _____________________________________________
E-mail: _________________________________________
I, ____________________________________________, grant permission for my child, ________________________________
to participate in the OLPH Teen ACTS Retreat that requires transportation to a location away from the parish site. I, also consent to the
use of any videotapes, photographs, slides, audiotapes, or any other video or audio reproduction in which my child may appear. I
understand these materials are being used for promotion of the youth ministry of Our Lady of Perpetual Help.
This activity will take place under the guidance and direction of parish employees and/or volunteers from Our Lady of Perpetual Help
Church, Selma, Texas.
Brief description of the activity is as follows:
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Type of Event – OLPH Teen ACTS Retreat
Date of Event –July 25 – July 28, 2013
Costs - $150.00 per high school student (includes meals, lodging, transportation, supplies & T-shirt)
o Deposit of $50.00 will hold spot.
o Cancelations after 07/04/13 will not be refunded.
Location of event –Eagle’s Wings Retreat Center, 2805 Ranch Road 2341, Burnet, TX 78611
Individual in charge – Amy Rubio-Youth Minister, 210-296-9663 / Cindy Tabor-Retreat Director, 210-394-4277
Transportation – Charter Bus (OK Tours) for Retreatants / Private vehicles for Team
Departure Date & Time –July 25, 2013, Retreatants @ OLPH - 5:30 pm
Return Date & Time –July 28, 2013 Retreat concludes with 5:00 pm Life Teen Mass (Families invited to attend)
Activities – Interaction with youth and adults concerning religious, spiritual, moral and social issues, prayer and
scripture sharing, physical games and exercises, indoor/outdoor activities.
As parent and/or legal guardian, I remain legally responsible for any personal actions taken by my minor child.
I agree on behalf of myself, my minor child herein, our heirs, successors, and assigns, to all of the above, and to hold
harmless and defend Our Lady of Perpetual Help Church, it’s officers, directors and agents, and the Archdiocese of San
Antonio from any and all liabilities for illness, injury or death arising from or in connection with my child’s attending the
above named event and I agree to compensate the parish, its officers, directors and agents and the Archdiocese of San
Antonio, or representatives associated with the event for reasonable attorney’s fees and expenses arising in connection
therewith.
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Parent/Guardian Name (PRINT)
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Parental Signature
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Date