Candidate Application

Candidate Application
* indicates required fields 

Candidate Information:

  *Name:
  *Address:
  *City:
  *State:
  *Zip Code:
  *Phone:
  *Email Address:
  *Date of Birth:
  *School:
  *Age:
  *Grade:
  *Parish:
  *Date of Weekend for which you are applying: Spring 2013   Fall 2013
  Mother's Name:
  Mother's Work Number:
  Mother's eMail Address:
  Father's Name:
  Father's Work Number:
  Father's Email Address:
  Parent's Address if Different from Above:
  *Have you ever been on a weekend retreat?:  Yes
 No
  If Yes, Which Ones?:
  *List any Church/School activities in which you are:
  *List your hobbies, interests, talents:
  *Name of your Journey Sponsor:
  *Has your sponsor answered your questions?:  Yes
 No
  *Are you aware that the Weekend starts on Thurs@ 6:30pm:  Yes
 No
  *Are you aware that the Weekend ends on Sun Evening:  Yes
 No
  *Why would like to participate in Journey?:
  *What do you hope to gain from Journey?:

Medical Information:

  *Allergies:
  *Required Medications (Include Dosages, Frequency, ect.):
  *Special Medical Conditions:
  *Special Dietary Considerations or Restrictions:
  *Date of Last Tetnus Booster:

Insurance Information:

  *Insurance/Carrier Name:
  *Policy Number/Group Number:
  *Name of Primary Person on Insurance:

Contact In Case of an Emergency:

  *Contact Name:
  *Home Phone:
  *Work Phone:
  *Cell Phone:

Backup Contacts In Case of an Emergency:

  *Primary Backup Name:
  *Primary Backup Phone:
  Secondary Backup Name:
  Secondary Backup Phone:

Please send your payment of $170.00 to:
St. Kateri Tekakwitha
ATTN: Journey Retreat
2216 Rosa Road, SCHENECTADY, NY 12309
Please make check payable to the Journey Retreat Program


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