This registration form is for adult chaperones attending one of the Confirmation retreats in Spring 2019. All fields marked with a red asterisk (*) are required. Select Confirmation Retreat Please select ONE * Saturday, March 23, 2019 at St. Elizabeth's, Ridgewood Saturday, April 6, 2019 at St. James, Upper Montclair Full information about the costs and deadlines for each of these Confirmation Retreat options is available on the Confirmation Retreats page. Participant Information Name * Church Affiliation * - Select -All Saints', Glen Rock (District 10)All Saints', Leonia (District 8)All Saints', Millington (District 3)All Saints' Episcopal Korean, Bergenfield (District 9)All Saints, Hoboken (District 6)Annunciation, Oradell (District 9)Atonement, Fair Lawn (District 8)Atonement, Tenafly (District 9)Calvary, Bayonne (District 6)Calvary, Summit (District 4)Christ Church, Bloomfield/Glen Ridge (District 5)Christ Church, Budd Lake (District 1)Christ Church, Hackensack (District 8)Christ Church, Harrison (District 6)Christ Church, Newton (District 2)Christ Church, Pompton Lakes (District 2)Christ Church, Ridgewood (District 10)Christ Church, Short Hills (District 4)Christ Church, Teaneck (District 8)Epiphany and Christ Church, Orange (District 5)Good Shepherd, Fort Lee (District 8)Good Shepherd, Lincoln Park & Montville (District 2)Good Shepherd, Ringwood (District 10)Good Shepherd, Wantage (District 2)Grace Church, Madison (District 4)Grace Church, Newark (District 4)Grace Church, Nutley (District 7)Grace Church, Rutherford (District 7)Grace Church, Union City (District 6)Grace Church, Westwood (District 9)Grace Church Van Vorst, Jersey City (District 6)Holy Communion, Norwood (District 9)Holy Communion, Paterson (District 10)Holy Innocents, West Orange (District 3)Holy Spirit, Verona (District 5)Holy Trinity, Hillsdale (District 9)Holy Trinity, West Orange (District 3)House of Prayer, Newark (District 4)Incarnation, Jersey City (District 6)Messiah, Chester (District 1)Our Saviour, Secaucus (District 6)Redeemer, Morristown (District 3)Saviour, Denville (District 2)St. Agnes & St. Paul's, East Orange (District 5)St. Agnes', Little Falls (District 5)St. Alban's, Oakland/Franklin Lakes (District 10)St. Andrew & Holy Communion, South Orange (District 4)St. Andrew's, Harrington Park (District 9)St. Andrew's, Newark (District 4)St. Anthony of Padua, Hackensack (District 8)St. Bartholomew's, Ho-Ho-Kus (District 10)St. Clement's, Hawthorne (District 10)St. Cyprian's, Hackensack (District 8)St. David's, Kinnelon (District 2)St. Dunstan's, Succasunna (District 1)St. Elizabeth's, Ridgewood (District 10)St. Gabriel's, Milton/Oak Ridge (District 2)St. George's, Maplewood (District 4)St. Gregory's, Parsippany (District 3)St. James, Upper Montclair (District 5)St. James', Hackettstown (District 1)St. James', Ridgefield (District 8)St. John the Divine, Hasbrouck Heights (District 7)St. John's, Boonton (District 2)St. John's, Montclair (District 5)St. John's, Passaic (District 7)St. John's, Dover (District 3)St. John's, Ramsey (District 10)St. Luke and St. Mary, Hope and Belvidere (District 1)St. Luke's, Haworth (District 9)St. Luke's, Montclair (District 5)St. Luke's, Phillipsburg (District 1)St. Mark's, Mendham (District 1)St. Mark's, Teaneck (District 8)St. Martin's, Maywood (District 7)St. Mary's, Sparta (District 2)St. Matthew's, Paramus (District 9)St. Michael's, Wayne (District 10)St. Paul's & Resurrection, Wood-Ridge (District 7)St. Paul's, Chatham (District 4)St. Paul's, Englewood (District 9)St. Paul's, Montvale (District 9)St. Paul's, Morris Plains (District 3)St. Paul's, North Arlington (District 7)St. Paul's, Paterson (District 10)St. Paul's, Jersey City (District 6)St. Peter's, Clifton (District 7)St. Peter's, Essex Fells (District 5)St. Peter's, Livingston (District 3)St. Peter's, Morristown (District 3)St. Peter's, Mount Arlington (District 1)St. Peter's, Mountain Lakes (District 2)St. Peter's, Washington (District 1)St. Stephen's, Millburn (District 4)St. Thomas', Lyndhurst (District 7)Trinity & St. Philip's Cathedral, Newark (District 4)Trinity, Allendale (District 10)Trinity, Bayonne (District 6)Trinity, Cliffside Park (District 8) Birth date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009 Gender * Male Female Email * Cell Phone * Street Address * City * State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip code * Any chronic conditions, food allergies, dietary restrictions or other issues we should know about Emergency Contact Name * Relationship * Phone * Safeguarding God's Children Have you completed Safeguarding God’s Children training within the last 5 years? Yes No Date of training Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2014201520162017201820192020 Upload copy of certificate Files must be less than 2 MB.Allowed file types: gif jpg jpeg png bmp pdf. Diocese of Newark Program Community Covenant (Responsibilities & Regulations)Our primary goal is to provide a safe, healthy, Christian environment for all participants. This covenant applies to ALL participants (youth, adult sponsors, clergy, speakers, etc.) Personal responsibilities (ALL ages & roles): To seek and serve Christ in all people. Respect the dignity of every human being and to work together as a community for the benefit of the group. There will be no alcohol, illegal drugs, knives (this includes pocket/jackknives) or weapons brought on the premises for any reason. Possession of sexually explicit materials is prohibited. In addition inappropriate, offensive, or sexually explicit communications or statements are prohibited. Smoking or using other tobacco products is prohibited in all buildings, meeting rooms and sleeping areas. Smoking by youth is prohibited. No pets/animals are allowed except trained service dogs. Participants must respect personal and public property. Repair costs for damages incurred to property will be billed to the individual responsible for the damage. Participants are asked to refrain from making noise in common areas and sleeping rooms during specifically named times with a named curfew for each program. To protect the safety of all participants at the event, no socialization between boys and girls is allowed in the participants’ sleeping areas or rooms. Adult chaperones and group leaders are responsible for enforcing the rules as stated. Violators of this Covenant may be asked to leave and/or be sent home. These rules are not subject to interpretation and each participant is expected to follow them without exception. If not able to attend the entire event, please do not attend. Required * I agree with the responsibilities and regulations of the Diocese of Newark Program Community Covenant