<p>January, 2017</p><p>Dear Seniors:</p><p>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.</p><p>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. </p><p>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.</p><p>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. </p><p>Peace,</p><p>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 </p><p>Parents: Please read and complete BOTH PAGES of this form. If you have any questions, please call Mr. LeBoeuf at 480-2192</p><p>Please print a response to all 5 of the following, even if some do not apply:</p><p>1) Student’s Name______</p><p>Mailing Address______City______</p><p>Zip Code______Cell Phone Number______</p><p>Student’s Email address______@______*************** 2) Father’s Name______</p><p>Address (if different from student)______City______</p><p>State/Zip______Hm. Phone ______Cell Phone______</p><p>Father’s Email Address______@______*************** 3) Mother’s Name______</p><p>Address (if different from student)______City______</p><p>State/Zip______Hm. Phone______Cell Phone______</p><p>Mother’s Email Address______@______*************** 4) Male Stepparent (please print “Not Applicable” if there isn’t one)</p><p>HisName______</p><p>Home Phone______Cell Phone______</p><p>Email Address ______@______*************** 5) Female Stepparent (please print “ Not Applicable” if there isn’t one)</p><p>Her Name______</p><p>Home Phone______Cell Phone______</p><p>Email Address ______@______</p><p>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):</p><p>______, 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.</p><p>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. *********************************************************************************</p><p>Son’s Date of Birth: ______</p><p>Physician’s Name (please print):______Office Phone Number:______</p><p>Medical Insurance Company:______Policy #:______</p><p>To which hospital near Auburn should we take him:______</p><p>Known Drug or Food Allergies:______</p><p>Last Tetanus Shot (Month/Year):______</p><p>Medication currently taking:______</p><p>Times and dosage of medication:______</p><p>Any special diet needs:______*************** Parent/Guardian Name (please print):______</p><p>Your Signature:______</p><p>Address/City/State/Zip:______</p><p>Home Phone:______Cell or Work Phone:______</p><p>Local Emergency Contact Person (please print):______</p><p>His/Her Work Phone #:______Home Phone #:______</p><p>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.</p>