LUKE 18, 2018REGISTRATION FORM

My son/daughter, ______has my permission to attend the Luke 18 retreat weekend at St. Paul parish, January 12, 13,14, 2018. Leaving for sports games or other activities (excluding medical or family emergencies) is not allowed as it disrupts the retreat experience for everyone.

Participant: ______M/F ____Grade: _____
Date of Birth: ______School: ______
Participant Email: ______

Circle T-Shirt Size:(T-shirts are ADULT size) SM MD LG XL XXL

Medical History

Physician Name: ______Physician Phone: ______
List Any Food, Pet or Other allergies: ______
List any Special Needs: ______

List any medications your child will be taking during the retreat weekend: (Prescription medication must have current pharmacy label with child’s name, medicine name and correct dose, time and Dr’s name).

Medication(s): ______Dose: ______Time: ______

  1. Child is responsible for taking medications according to his/her Doctor’s Orders: YES NO
  2. I authorizeYouth Minister, Sandy Reynolds,to give my child medication as prescribed: YES NO

Parent/Guardian Information

Parent Name(s): ______, ______

Home Address: ______City: ______, Zip: ______

Parent Email: ______
Parent(s) Phone: (H): ______, (C): ______, (C): ______

Agreements

  1. As the parent or guardian of ______(“child”), in signing this form, I hereby state that the information included in this form is correct and give permission for my child to participate in the activity entitled LUKE 18, 2018.
  2. I understand that my child will be under the supervision of the St. Paul YM staff and volunteers.
  3. I recognize that there are risks inherent in participation in any activity and agree to hold the St. Paul Catholic Church, Archdiocese of St. Louis, its affiliates and its and their employees, volunteers and agents, harmless from any injury to my child or damage to or loss of personal property of my child not caused by the negligence or misconduct of the St. Paul, Archdiocese of St. Louis, its affiliates and its and their employees, volunteers and agents.
  4. In the case of a medical emergency, I understand that every effort will be made to contact me, but in the event that I cannot be reached, I hereby give permission for my child to be evaluated, diagnosed and treated in accordance with standard medical practice by licensed medical personnel.
  5. I hereby give permission to St. Paul Youth Ministry to use any photographs or video footage taken of my child in print and on their website or social media for promotional purposes.
  6. I understand that for all Youth Ministry activities there is a zero tolerance policy for the use of any mood altering chemicals (including alcohol and illegal drugs), foul language, threats or any type of abuse and inappropriate physical contact. I agree to the follow this policy.

PARENT SIGNATURE: ______DATE: ______

PARTICIPANT SIGNATURE:______DATE: ______

In case of EMERGENCYDuring this Event,

Contact: ______, At This Number: ______

Retreat Payment of $55 enclosed (payable to “St. Paul”). Ck# ______. Cash______.