A Retreat with a Mission.

Who: All High School

Life rushes at us fast and we are Students
challenged to use our faith in those
situations. But can we use our faith to When: March 5th & 6th 2010
change the world?
Come join us for a 24-hour retreat that Where: St. Joseph Parish
will show you how your faith can 11311 Johnson Dr.
change your world. Shawnee, KS 66203

We will be learning specifically about Time: Friday 7 p.m. –

poverty and hunger in India. We will Saturday 7 p.m.
have guest speakers, learning activities
and games to dive into the culture of
Cost: $10/Person
India. We will also dedicate our
By Sunday, February 21st
weekend to Mother Teresa, the
($20/Person at the door and no guarantee
defender of Indian poverty. We will on a t-shirt if you sign up late)
experience what it is like to live, pray
and eat in India so we can unite with
them during Lent.

Soul Food 2010

 Life comes at you: Fast
This is the official registration form! Your parents must also fill out the following permission form.
Please include your $10 registration fee, checks payable to St. Michael the Archangel with “Soul Food” in
the memo line. You can return your completed registration, permission form, and payment to your Youth
Minister, or to Sara Batenhorst, St. Michael the Archangel, 14201 Nall, Overland Park, KS 66223.

Registrations are due February 21st!

Name __________________________________________________________________

E-mail address ___________________________________________________________

Address ________________________________________________________________

Home Phone ______________________ Cell Phone ____________________________

T-Shirt Size __________________

School _______________________________ Grade ____________

Parish ________________________________

Official Soul Food Retreat Information for Parents!

7 p.m. Friday, March 5, through Saturday, March 6
(Dinner and Closing for parents at 6 p.m. Saturday)

St. Joe Parish (Gym/Activity Center), 11311 Johnson Dr. Shawnee, KS 66203

In case of emergency during the actual retreat, you can contact your child by calling Chelsea Schmidt
(785-341-9562) or Chris Walters (913-486-9648).

We will not attend Sunday Mass on the retreat.

We ask that your child please eat dinner on Friday before arriving. Also, they will need to bring a
sleeping bag, pillow, change of clothes and toiletries. Please DO NOT bring a cell phone, iPod or food.
This Lenten retreat will help your student to enter into the spirit of the season through study of poverty,
education on social justice issues, a partial fast, prayer, games, and community building. You are invited
to join us for dinner at 6:00 p.m. on Saturday to close our retreat.

Parental/Guardian Consent Form and Liability Waiver

Soul Food Johnson County Lenten Retreat
March 5-6, 2010

Participant’s Name___________________________________ Birth Date_________________

Parent/Guardian’s Name________________________________________________________

Parent(s) Cell Phone ____________________________________________________________

Parent(s) Email ________________________________________________________________

I __________________________, grant permission for my child _________________________________ to participate in the

Soul Food Johnson County Lenten Retreat on March 5-6, 2010 at St. Joseph Parish in Shawnee, KS. I understand that staff and
volunteers of the Catholic Parishes of Johnson County will lead and chaperone this event.

For value received, I agree on behalf of myself, my child’s other parent, or guardian, my child named herein and/or our heirs,
successors, and assigns, to release, indemnify and hold harmless and defend the Archdiocese of Kansas City in Kansas, the
Church of the Nativity, other sponsoring parishes, and their priests, directors, officers, agents, volunteers, employees or
representatives associated with this event with respect to any and all actions, claims or demands that may be brought against
them arising from any injury or damage resulting from this event, and I agree to compensate the Archdiocese of Kansas City in
Kansas, the Church of the Nativity and their priests, directors, officers, agents, representatives, volunteers, employees or
representatives for attorney fees and expenses incurred as a result of any such injury or damage, unless such claim arises from
their negligence of those released.

Medical Matters: I hereby warrant that to the best of my knowledge my child is in good physical and mental health, and I
assume all responsibility for the health of my child. Of the following statements pertaining to medical matters sign only
those in accordance with your wishes.

I understand that this retreat will include a partial fast. Food served will consist of 2 light meals reflective of the
impoverished Indian culture. No snacks will be served. Water and juice will be available. Food will be made available
for those with medical conditions making it unsafe to fast. All students should consult their physician before fasting
from food.

I agree that my child can undertake the fast at this retreat.

Parent Signature: _________________________________________________________

Emergency Medical Treatment: In the event of a medical emergency, I give permission to the staff of the Church of the
Nativity and other persons associated with the event to transport my child to a hospital for emergency medical or surgical
treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you
are unable to reach me at the above number, contact:

Name and Relationship _________________________________________ Telephone (______) ____________________

Family Doctor _________________________________________________ Telephone (______) ____________________

Family Health Plan Carrier ______________________________________ Policy Number _______________________

(1) Parent Signature: ____________________________________________ Date: ________________________

Other Medical Treatment: In the event it comes to the attention of the chaperones or representatives associated with this
event, that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called.

(2) Parent Signature: ___________________________________________ Date: _______________________________

Medications: My child is taking medication at present. My child will bring all such medications necessary and such
medications will be well-labeled. Names of medications and concise directions for seeing the child takes such medications,
including dosage and frequency of dosage are as follows:
___________________________________________________________________________________________________

(3) Parent Signature: __________________________________________ Date: ________________________________

Please only sign one of the two following statements.

No medication of any type whether prescription or non-prescription may be administered to my child unless the situation is
life-threatening and emergency treatment is required.

(4a) Parent Signature: __________________________________________ Date: _______________________________

I hereby grant permission for non-prescription medication (such as Tylenol, throat lozenges, cough syrup) to be given my child
if deemed advisable.

(4b) Parent Signature: __________________________________________ Date: _______________________________

Specific Medical Information: Reasonable care will be taken to see that the following information will be held in
confidence.

Allergic reactions (medications, foods, plants, insects, etc.): ______________________________________________

Immunizations: Date of last tetanus/diphtheria immunization: _____________________________________________

Does child have a medically prescribed diet? _____________________________________________________________

Any physical limitations? _____________________________________________________________________________

Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting, etc.?
___________________________________________________________________________________________________

Has child recently been exposed to contagious disease or condition such as mumps, measles, chicken pox, etc.? If so, date and
disease or condition: ______________________________________________________________________________

You should also be aware of these special medical conditions of my child: ______________________________________
___________________________________________________________________________________________________

Code of Behavior: I agree that my child shall abide by all rules and regulations governing the behavior of attendees at this
event. I agree that if my child fails to abide by the rules and regulations, my child can be immediately dismissed from the
event and sent home immediately at my expense with no right of reimbursement for any amount incurred in connection with
the dismissal and trip home.
I fully understand the consequences of the foregoing statements and sign this Parental/Guardian Consent Form and
Liability Waiver knowingly, freely, and willingly. (Your signature must appear below or your child will not be permitted to
participate.)

(5) Parent Signature: ______________________________________________ Date: ______________________________

I understand and agree to follow the rules and regulations governing my behavior during this event. I also understand and
agree that my parent(s) or guardian will be notified at the time of any infractions requiring my dismissal from the trip and that I
will be sent home at my own or my parent or guardian’s expense. Being found with any alcoholic beverages, drugs, or
weapons is cause for automatic dismissal from the event. (Your signature must appear below or you will not be permitted to
participate.)

(6) Student Signature: _____________________________________________ Date: _______________________________