C4 Summer Retreat

*Submit an individual form for each child.

* Retreat is July 18th-20th

* The retreat is for high school-aged students who received Confirmation before June 2025 and are interested in being part of the C4 Team during the 2025-2026 school year.

* A $40 non-refundable deposit is required at the time of registration.

* The total retreat price is $100. *Total price may go down based on upcoming fundraiser*

* The final Registration and Payment Due Date is 6/30/25.

Family Name (last name)

Mailing Address

City

State

Zip Code

PARENT/GUARDIAN INFORMATION

Name of Mother

Mother's Cell Number

Name of Father

Father's Cell Number

Email (one email only)

Teen's Information

Teen's full Name

Teens Date of Birth

Gender

Grade

Please do not put current grade

Sacraments Celebrated (select all that apply)

Baptism

Reconciliation

Eucharist

Confirmation

None

Teen's Cell

HEALTH INFORMATION

Health Issues/Medications/Conditions/Special Concerns (Catechists and aides will not distribute medication, prescription or non-prescription.).

EMERGENCY CONTACT INFORMATION/ALTERNATIVE RELEASE

Alternate/Emergency Contact Name(Not Parent)

Emergency Contact Cell Phone

Name of adult to whom we may release your child (other than biological parent or legal guardian)?

Release Adult Cell Phone

PERMISSIONS

TexPhoto/Video Consent and Release (Parent's/Guardian's initials required below)

I hereby authorize St. James Catholic Church to take photographs, recordings, and/or videos (whether electronic, digital, or otherwise) of Participant in connection with the activities, and I hereby consent to the use, reproduction, and publication of such images by St. James Catholic Church in connection with the promotion and publicity of the activities of St. James Catholic Church, including, without limitation, publication of such images on St. James Catholic Church's website, media, etc. I, individually and in my capacity as parent/legal guardian of Participant, hereby waive any right to inspect or approve the actual use by St. James Catholic Church of any such image of Participant. Such images of Participant shall be the sole property of St. James Catholic Church, and I, individually and in my capacity as parent/legal guardian of Participant, acknowledge and agree that neither I nor Participant shall be entitled to any compensation whatsoever should any such images of Participant be used by St. James Catholic Church. Permission for Photo/Video Consent and Release - Parent's Initials Required Below

C4 Summer Retreat FEE

NON REFUNDABLE FEE of $40.00. $40.00 per child

INQUIRIES:

Adam Klapuch

 830-263-1418

klapuch.adam@gmail.com