2016 Jr. Louisiana KPC
Expansion Picnic-SWCC-DISTRICT 6
Saturday, August 27, 2016
From:
Southwest Central Committee District VI, Knights of Peter Claver-Lake Charles
Louisiana Junior Expansion Picnic Committee
To:
National Officers, Louisiana States Officers, State Director Junior Knights,
State Directress Junior Daughters, Grand Knights, Grand Ladies,
Junior Knight Commanders, Junior Daughter Counselors, Junior Knights, Junior Daughters
Re:
Louisiana Junior Expansion Picnic
Saturday, August 27, 2016
Fraternal Greetings:
The members of Southwest Central Committee District VI of Louisiana are please to host the 2016 Louisiana
Junior Expansion Picnic: Rigmaiden Recreation Center (Mossville)
Location: 3825 Old Spanish Trail, Westlake, La. 70669
The fun filled day is scheduled as follows:
Registration……………………………8:30A.M. - 9:45A.M.
Prayer Service………………………..10:00A.M.
Educational Session………………..10:45A.M.
Game Tournament………………….11:30A.M.
Lunch………………………………………12:00 Noon
Competitions…………………………..1:00P.M.
Close...........................................3:00P.M.
Please pre-register your group by August 1, 2016. Remember to send the names of guest(s) as well as Junior
Knights and Junior Daughters, who will be attending from your Branches/Courts. This information is essential
to facilitate effective planning for the youth attending this event. Name tags will be prepared for those
attending, which will show their name and branch/court. We also need to know what games or activities your
group would like to participate in. Applications for new members will be available on site.
Please make one (1) copy of your registration form to keep and send the original to:
Lady Jackie Simien-Guillory
2117 12th Street
Lake Charles, Louisiana 70601-6563
If you have any questions, please do not hesitate to contact Picnic Chair- Lady Jackie Simien-Guillory at (337)244-1222 or
Brother Marshall Simien at (337) 497-0022.
We, look forward to seeing all of you at the picnic.
Sincerely,
Louisiana Junior Expansion Picnic Planning Committee- District VI (Southwest Central Committee)
2016 Jr. Louisiana KPC
Expansion Picnic-SWCC-DISTRICT 6
Saturday, August 27, 2016
1.PLEASE READ AND FILL EACH FORM.
2.SEND ORIGINAL(S) AND RETAIN 1 COPY OF ENTIRE PACKET FOR
TRAVEL3.Please have all necessary signatures for all forms.
4.Return by Deadline: August 1, 2016
Checklist:

Cover letter

Registration Form & extra sheet - Commander/Counselor signatures, email, phone numbers-
please include prospective members Junior or Senior- lets grow!

Registration Participation (games) Commander/Counselor signatures, email, phone numbers

KPC Child Protection Policy- Diocesan training certificate copy, (Sr. Seal needed)
 Signatures: Grand Knight/Grand Lady & Commander/Counselor & Adult
Attendee

Parental Release/Consent Form-

Media Release

Directions: East/ West, Picnic Contacts

Reminder Note

Deadline Flyer
youth and parent signature- insurance info
-parent signature
PLEASE BRING LAWN CHAIRS, SUN BLOCK, CANOPY, BLANKETS, INSECT REPELLENT…ETC
Mail packets to:
Lady Jackie Simien-Guillory
2117 12th Street L.C., LA. 70601-6563
337-244-1222
2016 Jr. Louisiana KPC
Expansion Picnic-SWCC-DISTRICT 6
Saturday, August 27, 2016
Location:
Rigmaiden Recreation Center (Mossville)
3825 Old Spanish Trail
Westlake, La. 70669
‘Pre’ – Registration June 29th thru July 31, 2016
DEADLINE: August 1, 2016
Mail Registration Packet to:
Lady Jackie Simien- Guillory
2117 12th Street
Lake Charles, La. 70601-6563
337-244-1222
2016 Jr. Louisiana KPC
Expansion Picnic-SWCC-DISTRICT 6
Saturday, August 27, 2016
Registration Form
Deadline August 1, 2016
Please mail this registration form for Junior Knights and Junior Daughters to: Registration Chairperson
Name and Number of Junior Knight Branch or Junior Daughter Court
________________________________________________________________________#_______________
City ______________________________________________________________________District#_________
Commander/Counselor Name (Signature and Print)
_______________________________________________Print: ______________________________________
Phone#_________________________________________Email______________________________________
Total of Juniors Attending from your Unit______________________Visitors___________________________
WILL YOU BE COOKING FOR YOUR GROUP? YES OR NO (so we may prepare accordingly)
Place name of each person who will attend on a line; AGE or A=ADULT; KNIGHT OR LADY OR JR.; CHAPERONE
NAME (print)
(PLEASE LIST ATTENDEES)
1.
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AGE
(A)
CHAPERONE/MEMBER/
PROSPECTIVE MEMBER
NAME (print)
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AGE
CHAPERONE/MEMBER/
PROSPECTIVE MEMBER
2016 Jr. Louisiana KPC
Expansion Picnic-SWCC-DISTRICT 6
Saturday, August 27, 2016
REGISTRATION FORM & PARTICIPATION FORM
(Please Print All Information Legibly)
Name and Number of Junior Knight Branch or Junior Daughter Court:
________________________________________________________________________#_______________
City: ______________________________________________________________________District#_________
Commander / Counselor Name
Sign___________________________________________________Print________________________________
Phone Number
Home: _________________________________________________Cell________________________________
Email_____________________________________________________________________________________
Activity
Potato Race (Individual)
Hula Hoop (Individual)
Sack Race
Three Legged Race (2 members)
Relay Race 3 member team
3 on 3 basketball tournament
Bean Bag Toss
Volleyball (6 member Team)
Balloon Water Toss
8 on 8 flag football
Dunking Booth
Minute to win it
Egg toss
Kick ball
Karaoke
Spoon race (marshmallows)
Educational Topic:
# of Individuals Participating
Age Group: 7-12
# of Individuals Participating
Age Group: 13-18
Law Enforcement: your POWER
and friend in Claverism
Several topics will be covered
Calcasieu Parish Sheriff Dept. /LA
Troopers
2016 Jr. Louisiana KPC
Expansion Picnic-SWCC-DISTRICT 6
Saturday, August 27, 2016
I acknowledge that I have received, read, understand, and agree to comply with the following policies in effect
for the Knights of Peter Claver Inc.
KPC CHILD PROTECTION POLICY
I understand that any action inconsistent with the policy listed above, or my failure to take action mandated
by these policy and programs may result in disciplinary action, up to and including the termination of my
voluntary service.
Adult Attendee/Chaperone: ___________________________________________________________________
Council/Branch/Court: ______________________________________________________________#________
City: ______________________________________________________________________________________
Signature: (Adult Attendee/Chaperone)
____________________________________Date__________________
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
COMMANDERS AND COUNSELORS PLEASE COMPLETE BOTTOM ALONG WITH SR. GRAND KNIGHT/LADY
I CERTIFY THAT THE ABOVE INDIVIDUAL HAS COMPLETED THE DIOCESAN TRANINING AND BACKGROUND
CHECKS IN COMPLIANCE WITH THE National KPC CHILD Protection Policy
Commander/Counselor SIGNATURE____________________________________________Date___________
Sr. Grand Knight/Lady_______________________________________________________Date____________
PHONE: ______________________________________________
********ALL SENIORS / ATTENDEES MUST HAVE A COMPLETED FORM IN ORDER TO ATTEND********
PLEASE PRINT OR TYPE ALL INFORMATION
-+ATTACH A COPY OF DIOCEASAN TRAINING
Council Seal
Court Seal
Form must contain seal to be accepted
2016 Jr. Louisiana KPC Expansion Picnic-SWCC-DISTRICT 6
Saturday, August 27, 2016
Release and Consent Form
PARENTS: I, ___________________________________________Parent( ) Guardian( ) the undersigned, give
permission for my son/daughter ___________________________________________to attend the 2016 Louisiana
Expansion Picnic in Lake Charles, LA. on August 27, 2016. It is understood that reasonable caution will be taken by those
persons in charge to prevent injury. In consideration of my child being permitted to participate in the 2016 Expansion
Picnic, I personally and on behalf of my child, hereby release the Knights of Peter Claver, Inc., their members, their staff,
their officers, their volunteers, the coordinators and chaperones from any liability of injuries or damages arising or
resulting from participation in the 2016 Louisiana Jr State Expansion Picnic and/or transportation to and from the
activity. In the event that I cannot be reached, I hereby grant permission for my son/daughter to be evaluated,
diagnosed, treated and or medicated in accordance with standard medical practice by licensed medical personnel. My
child agrees to abide by all rules and regulations as outlined in the KPC Juniors Code of Behavior. I understand that KPC
will not be held liable if my child fails to cooperate with said regulations and that any infraction of the rules may result in
immediate dismissal from the 2016 Louisiana Jr. State Expansion Picnic. I will be responsible for any costs or other
requirements for immediate transportation home. The medical information for my child is as follows:
Medical Information
Branch or Court Name & Number__________________________________#_________
My child is allergic to: (MEDICATION/FOOD):
______________________________________________________________
My child must take the following medications (dosage, frequency etc.) ________________________________________
Special Medical conditions or needs of my child (dietary, asthma, insect sting allergies, other conditions)
__________________________________________________________________________________________
Please Provide ALL necessary information about insurance:
Insurance Carrier: ________________________________________PolicyCarrier_________________________________
Policy #____________________________________________Benefits/Plan/Group#______________________________
Date Last Tetanus Booster____________________________
In case of emergency notify: _____________________________________________________Relationship: _________
Cell phone: __________________________________________2nd Number_____________________________________
Third party Contact (somebody that can reach you, relative, etc.)
___________________________________________________Ph#____________________________________________
Parents Signature_________________________________________________________________date_______________
YOUTH PRINT___________________________________________________________I HAVE READ BELOW YES OR NO
As a member or visitor of the Knights of Peter Claver, Junior Knights/Junior Daughters, I understand and agree to the KPC Jun ior
Knights /Junior Daughters Code of Behavior. I understand that sagging pants, extremely short or tight outfits or any other
inappropriate clothing is not allowed. I also understand and agree that my parents or legal guardian will be notified at the time of
any infractions occurring during this event and all expense(s) will be that of my parents.
2016 Jr. Louisiana KPC
Expansion Picnic-SWCC-DISTRICT 6
Saturday, August 27, 2016
MEDIA RELEASE-PARENTAL CONSENT FORM
I, (parent/print) _______________________________________do hereby certify that I am the parent/legal
guardian/ of (child)____________________________________a minor. I am fully qualified and authorized to
execute this Parental Consent Form. In my aforementioned capacity, I do hereby consent to the
photographing and videotaping, as well as the use, portrayal, posting, publishing or otherwise the above
named minor’s image, likeness, photograph, video footage and /or other depiction at or in conjunction with
2016 LA. Jr. KPC State Expansion Picnic, Yearbook and any other Publication. The foregoing consent is given
with the understanding that the published depiction of the said minor shall be tasteful and in compliance with
the law and /or other applicable regulation. I shall retain the right to revoke this consent following the
execution hereof, upon 30 days’ written notice to the Knights of Peter Claver, Inc. The Knights of Peter Claver,
Inc., shall have the exclusive right to the design and to the manner by which the minor’s name and or image
shall be displayed in the final publication. The Parental Consent Form constitutes a knowing waiver of any
right, claim or legal cause of action that I or the above-named minor may have arising from the use, portrayal,
posting, publishing or otherwise displaying of the minor’s image, likeness, photograph video footage and or
other depiction at or in conjunction with 2016 LA Jr. KPC State Expansion Picnic, yearbook, and any other
publication.
I HAVE READ THE ABOVE AND FOREGOING PARENTAL CONSENT FORM AND FULLY UNDERSTAND THE TERMS
THEREOF:
PRINTED____________________________________SIGNATURE___________________________________
DATE______________________________ PHONE______________________________________________
BRANCH OR COURT _____________________________________________#_________________________
2016 Jr. Louisiana KPC
Expansion Picnic-SWCC-DISTRICT 6
Saturday, August 27, 2016
Directions : Follow these instructions due to major construction in area
 I-10 west cross the I-10 bridge get into far right lane keep
straight
 PPG-Drive/Trousde
 After passing under the exit sign get over in left lane –
 Highway 90 continue straight (2nd red light Prater Rd)
 Right Turn on Prater Road cross railroad tracks continue to
Stop Sign
 (Sulphur/Westlake) turn Right toward Westlake (Old
Spanish Trail)
 Rigmaiden Recreation Center on left

Directions: Bro. Paul Jones (337) 540-5327
Picnic Contacts:
SWCC District President: Gracious Lady Michelle C. Jackson (337)488-7883
Logistic/ Overall: Bro. Marshall Simien (337)540-3495
Gracious Lady Jackie Simien- Guillory (337)244-1222
Games/Tournament: Bro. John Coleman 337 513 7963
Health: Lady Tennille Harmon 337 309 1200