Kairos 2024-2025 / 2-Parts Registration

Kairos is a 3-Days / 2 Nights Overnight Senior Retreat

Location: Vallombrosa Retreat Center, Menlo Park, CA

All meals and snacks are included. STUDENTS MAY NOT PACK SNACKS, CANDY, GUM OR DRINKS - these will be confiscated or thrown away before departure.

All students will meet at De La Salle High School at 8:30 am in front of the LAPC lobby on the Quad side on the first day to depart by bus provided by DLS at 9:00 am sharp. All students will return to De La Salle High School by bus on the third day by 5:30 pm.

Each student will need to bring an overnight bag with toiletries, warm, comfortable clothing, and some closed shoes. A student could bring their favorite pillow but it is not necessary.

All bags will be inspected and all bottles emptied by a DLS administrator prior to getting on the bus.

Students will turn in their cell phones upon arrival at retreat and they will be kept under lock and key for the duration of the retreat.

In this form, you will provide required medical and contact information for De La Salle High School. This is Part 1 of a 2 Part Registration. Make sure to fill out Part 2 without which registration is not confirmed.

Student Last Name*

Last Name

Student First Name*

First Name

Student De La Salle Email*

12345@dlshs.org

Kairos Dates 2024-2025*

Waiting List - If the Kairos Retreat that you want is full, please type in the retreat number that you'd like to be added to if a spot opens up.

Does Parent / Guardian / Parent-Figure need translation? If so, into what language

Please type the language that communication from Campus Ministry needs to be translated into.

Does Parent / Guardian / Parent-Figure have access to a computer?*

YesNo

Can Parent / Guardian / Parent-Figure use a computer without the help of the student who is registering?*

YesNo

How many Parents / Guardians / Parent-Figures does the student have?

Parent / Guardian / Parent-Figure (1) Last Name*

Last Name

Parent / Guardian / Parent-Figure (1) First Name*

First Name

Relationship to Student Registering - Parent / Guardian / Parent-Figure (1):*

(e.g., Mother; Father; Step-Mother; Step-Father; Guardian; Grandmother, etc...)

Email - Parent / Guardian / Parent-Figure (1)*

Enter n/a if not applicable

Phone # - Parent / Guardian / Parent-Figure (1)*

Area CodePhone Number

Phone # - Alternate - Parent / Guardian / Parent-Figure (1)

Area CodePhone Number

Parent / Guardian / Parent-Figure (2) Last Name*

Last Name (Enter n/a if not applicable)

Parent / Guardian / Parent-Figure (2) First Name*

First Name (Enter n/a if not applicable)

Relationship to Student Registering - Parent / Guardian / Parent-Figure (2) *

(e.g., Mother; Father; Step-Mother; Step-Father; Guardian; Grandmother, etc...) (Enter n/a if not applicable)

Email - Parent / Guardian / Parent-Figure (2) *

(Enter n/a if not applicable)

Phone # - Parent / Guardian / Parent-Figure (2) *

(Area Code)-Phone Number (Enter n/a if not applicable)

Phone # - Alternate - Parent / Guardian / Parent-Figure (2)

(Area Code)-Phone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

General Medical Information

Indicate your student's health considerations and some basic medical information.

De La Salle staff can administer over-the-counter medications to my student if needed, including but not limited to: Ibuprofen, Acetaminophen, Benadryl, Hydrocortisone, and others).*

YesNo

Special health considerations (allergies, dietary needs and dietary allergies, limited physical activity, etc.). If none, please type NONE.*

Epi-Pen (Fill "Yes" or leave blank)

Medication(s) and Dosage(s)

Medical Insurance Plan and Number*

Family Doctor*

Doctor Phone Number*

Area CodePhone Number

Confirmation Email*

Confirmation email will be sent to this address.

PLEASE NOTE: This is part 1 of a 2 part registration. When you hit SUBMIT, you will be directed to fill out PART 2. Your registration is INCOMPLETE and cannot be confirmed until PART 2 is filled.