January, 2017

Dear Seniors:

KAIROS 134 leaves after school Tuesday, February 21, and arrives back at Jesuit at 5:45 p.m. Friday, February 24. KAIROS 134 is your final opportunity to make a KAIROS retreat. I encourage you to take advantage of this opportunity.

The KAIROS tradition is a very important reality at Jesuit. KAIROS not only impacts the lives of the upperclassmen, but it has a profound impact upon the entire school community from faculty to freshmen.

In order for you to register for KAIROS, please have your parent(s) complete both sides of the attached form. Space cannot be confirmed until you turn in your form with your parent’s signature.

We can take up to 48 retreatants for KAIROS 134. We will begin accepting applications immediately, and will continue accepting until the retreat is full.

Peace,

Mr. Paul LeBoeuf Director of Campus Ministry CAMPUS MINISTRY - KAIROS 134 Leaves Tues., February 21 after school and returns Fri., February 24, 2017 at 5:45 pm

Parents: Please read and complete BOTH PAGES of this form. If you have any questions, please call Mr. LeBoeuf at 480-2192

Please print a response to all 5 of the following, even if some do not apply:

1) Student’s Name______

Mailing Address______City______

Zip Code______Cell Phone Number______

Student’s Email address______@______*************** 2) Father’s Name______

Address (if different from student)______City______

State/Zip______Hm. Phone ______Cell Phone______

Father’s Email Address______@______*************** 3) Mother’s Name______

Address (if different from student)______City______

State/Zip______Hm. Phone______Cell Phone______

Mother’s Email Address______@______*************** 4) Male Stepparent (please print “Not Applicable” if there isn’t one)

HisName______

Home Phone______Cell Phone______

Email Address ______@______*************** 5) Female Stepparent (please print “ Not Applicable” if there isn’t one)

Her Name______

Home Phone______Cell Phone______

Email Address ______@______

Jesuit High School Retreat Permission Slip and Emergency Medical Release Form 2016-2017 The Undersigned, who is a parent or legal guardian of (print student’s name):

______, a minor, hereby authorizes and consents to the attendance and participation of said minor in this retreat and give him permission to make use of the chartered bus transportation supplied by Jesuit High School to and from the Jesuit Retreat Center of the Sierra in Applegate, and sleep over at the center.

The Undersigned authorizes any adult Retreat Director to consent, in the case of any accident or illness, to any treatment of the above minor by a licensed medical physician and/or surgeon and/or dentist, or any hospitalization necessary, and/or to provide first aid - all in the case of an emergency when the parents are not readily available. The Undersigned agrees to pay any and all costs associated with treatment not covered by their insurance. *********************************************************************************

Son’s Date of Birth: ______

Physician’s Name (please print):______Office Phone Number:______

Medical Insurance Company:______Policy #:______

To which hospital near Auburn should we take him:______

Known Drug or Food Allergies:______

Last Tetanus Shot (Month/Year):______

Medication currently taking:______

Times and dosage of medication:______

Any special diet needs:______*************** Parent/Guardian Name (please print):______

Your Signature:______

Address/City/State/Zip:______

Home Phone:______Cell or Work Phone:______

Local Emergency Contact Person (please print):______

His/Her Work Phone #:______Home Phone #:______

In case you need to call your son for an emergency: Jesuit Retreat Center of the Sierra, Applegate Phone #: 530-878-2776. Please make note of this number.