ANTIOCH FALL Retreat - Our Lady of Mt Carmel Catholic Church

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Keep this Page for your records As a community that strives to deepen its Catholic faith, Antioch works to glorify God by bringing His word to others through support, service and example to fulfill our call to love.

What is an Antioch Weekend? The Acts of the Apostles record that “it was at Antioch that the disciples were first called Christians.” (Acts 11:26) During the early time of the church, the community at Antioch was recognized as a particularly faithful, vibrant, loving, prayerful people of God.

What is the weekend like? It is a dynamic weekend full of sharing, discussion, music, fun, projects, and more. This weekend is facilitated entirely by experienced high school youth with the help of a few Adult spiritual directors. You will be glad you came!!

Who can go? The Antioch weekend will be held on the OLMC campus October 27-29, 2017. It is open to Sophomore through Senior students. An open heart is all that is required to make it a meaningful weekend for you and your friends.

How do I register? Just complete the registration form, have your parents fill out the Media Release and Medical Emergency portion, and send it along with a check for $60.00 made payable to Our Lady of Mount Carmel. Please note that registrations for the weekend are limited in number, and applications will be processed as received. The deadline to turn in your registration is Friday, October 20, 2017. However, if the quota is met prior to this date, remaining names will be placed on a waiting list in the order received. If you have any questions, please call Louis Paiz at 317-663-4004 or email at [email protected]

Where do I mail the registration form? Our Lady of Mount Carmel 14598 Oak Ridge Rd Carmel, Indiana 46032 Attn: Louis Paiz Keep this Page for your records Please return REGISTRATION form and payment to the Faith Formation office no later than Friday, October 20, 2017.

CANDIDATE Registration / ANTIOCH FALL Retreat

(Top protion to be completed by Candidate)

Preferred Name___________________________

Date__________________ Gender: M / F


School Attending_____________________________

Parent E-mail__________________________________________ Adult T-shirt size: S



Youth Email____________________________________________Age____________ Grade___________ My hobbies are:


CK#______________ PAL______________

I would describe myself as:


I would like to come to this weekend because:


I heard about the retreat from: Other retreats/conferences I have attended: CANDIDATE: I plan to attend the entire Antioch Retreat weekend, October 27-29, 2017. I have enclosed a check for $60.00 with this registration *For Financial Assistance, please request a Financial Assistance form in the Faith Formation office. **The deadline to turn in your registration is Friday, October 20, 2017. However, if the quota is met prior to this date, remaining names will be placed on a waiting list in the order received.

Candidate Signature___________________________________________________ Parental Permission for High School Candidate (This portion is to be completed by Parent)

We, the parents or guardians of_____________________________, permit our son or daughter to participate in the Antioch Retreat weekend held on the OLMC parish grounds from Friday, October 27, 2017; 7:00pm through Sunday, October 29, 2017; 4:00pm. We, the parents/guardians of the undersigned minor, hereby consent to hold harmless, the Roman Catholic Diocese of Lafayette-in-Indiana, Inc., and any and all employees or volunteers thereof, for any accident, injury or occurrence arising out of, or in connection with the activity and our child’s event arranged transportation necessary to participate in the aforementioned activity. I give my permission for my son/daughter, in case of an emergency, to be taken to a physician or hospital by either a parent in charge or by parish personnel. I understand that every effort will be made to contact me. I understand that this event is being carefully and professionally planned and it is to be held at OLMC parish for the entire weekend. I am aware that the youth will be sleeping in assigned sleep groups separated by gender, in the homes of Host Families; the adults of which have completed the online protocol training “Protecting God’s Children in the 21st Century” and have met diocesan standards for working with youth. I understand that upon arrival at Check-in on Friday, I will find out the Host Home name and contact information of where my son or daughter will be sleeping. I fully expect to be notified if he or she is disrespectful or uncooperative. I know that great care will be taken and that my child will be offered plenty of good food and rest. My child has the following health conditions or is in need of the following diet or medication as stated in the Medical Emergency Waiver on the next page.

Please fill out both Media & Medical Emergency information on the back of this sheet. Parent Permission/Signature___________________________________________________Date__________________

Our Lady of Mt. Carmel Parish Media Release We believe that both the youth and the parish benefit from positive recognition. There may be occasion for Catholic media coverage concerning your youth throughout the retreat. We ask permission to release this type of communication. This could include: Newspapers, newsletters, The Observer, The Catholic Moment and the OLMC and Diocesan websites. ______ Yes. The parish has my permission to release Antioch related communication involving my youth to the media. ______ No. The parish does not have my permission to release Antioch related communication involving my youth to the media.



Parent Signature


ANTIOCH RETREAT MEDICAL EMERGENCY WAIVER ________________________________________________________________ ____________________ ________________________________ STUDENT: Last Name, First Name


Date of Birth

____________________________________________________________________ ___________________________ _____________________________



Zip Code

__________________________ ________________________ ______________________________ ____________________________________ Father’s Home phone #

Work Phone #

Cellular Phone #

Father’s Name

__________________________ ________________________ ______________________________ ____________________________________ Mother’s Home phone #

Work Phone #

Cellular Phone #

Mother’s Name

Who does your teenager live with?

_________________________________________________________________ In case of an emergency, if parent is not available, please contact: (List 2 friends or relatives) 1.______________________________________ ________________________ _________________________ Full name

Phone #


2. _____________________________________ ________________________ __________________________ Full name

Phone #


Do we have your permission to administer Benadryl / Diphenhydramine HCL? Yes No (Circle One) I hereby grant permission for nonprescription medication (such as Tylenol, throat lozenges, cough syrup) to be given to my child _______parent initial Please DO NOT administer the following: _________________________________________________

Youth prefers Vegetarian meals: Yes

No (circle one)

Please list allergies (Pets, Food sensitivities, medications, bee stings, etc):_______________________________ Will your child require medication during this retreat?


No (circle one)

If Yes: *Medication _______________________________ Dosage_____________________________ Time_____________ *Please note: All prescribed medication must be brought in its original container with dosage instructions on container and placed in a zip-loc bag.

Any additional information you can provide to help our adult team minister to your teenager during this spiritual retreat will be appreciated. (Any relevant struggles ie: anxiety, depression, recent loss, sensitivity, emotional or any concerns you would like to share with us.) This information is kept confidential. Please contact Louis Paiz at [email protected]. Child’s Physician: ______________________________ Office Phone: ______________ After Hours: _________________ Hospital Preference:__________________________________________________________ Medical Insurance Provider ____________________________________ Policy #________________________________ I give my permission for the Church personnel to obtain needed medical services and transport to a hospital in case the named student suffers illness or accident and the parent cannot be contacted. ________________________________________________________ Parent Signature

_____________________________ Date