This registration form is for youth attending one of the Confirmation Retreats in Spring 2018. All fields marked with a red asterisk (*) are required. Select Confirmation Retreat Please select ONE * February 24, 2018 at St James' Church, Upper Montclair March 3, 2018 at Christ Church, Pompton Lakes March 24, 2018 at Grace Church, Madison Full information about the costs and deadlines for each of these Confirmation Retreat options is available on the Confirmation Retreats page. Participant Participant's name * Birth date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008 Gender * Male Female Grade in school 2017-2018 * - Select -89101112 Participant's email Cell phone Any chronic conditions, food allergies, dietary restrictions or other issues we should know about Medications Please list all medications (including over-the-counter or non-prescription drugs) and the reason for taking. All medications must be in the original container that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage and frequency of administration. Date of last tetanus shot Parent / Guardian InformationIMPORTANT: The parent/guardian authorization form, which must be printed, signed and returned in order to complete registration, will be emailed to the name and email address of the person listed below. Name * Email * 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) 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 * Cell phone Daytime phone Emergency phone Other contact (with relationship) Physician's name & phone Do you have health or medical insurance Yes No If so, upload copy of insurance card (not required) Files must be less than 2 MB.Allowed file types: gif jpg jpeg bmp pdf. Name & relationship of person picking up child (if not self) * Parents' / Guardians' Covenant I promise to pick up my child on time from the event in accordance with the diocesan Policy Regarding End of Event Supervision. I authorize an adult in whose care the minor has been entrusted to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment or hospital care, to be rendered to the minor under the general or specific supervision and on the advice of any physician or dentist under the provisions of the Medical Practice Act on the medical staff of a licensed hospital. I will be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to the above-named person pursuant to this authorization. I give my permission for photographs and/or video footage of my child to be used by the Diocese of Newark for promotional purposes (brochures, on diocesan websites, promotional videos, presentations, etc). I hereby give permission for this person to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in this event. I have read and understood the Community Covenant. I understand that the participant must respect and obey the instructions of the adults in charge and that tobacco, alcohol, illegal drugs, weapons, inappropriate sexual behavior or sexually explicit communications will not be permitted at the event. I understand that the Diocese cannot assume responsibility for valuables or electronic equipment brought to the programs without authorization. I will provide transportation home for the young person if problems occur during this event. I will take no civil action or legal action against the adults in charge of the Diocese of Newark Program. Required * I agree with the Parents'/Guardians' Covenant When you click the Submit button below, you will be redirected to a page with both an online payment option, and instructions for paying by check.