Our Lady of Grace Church St. Joseph S Church

Our Lady of Grace Church St. Joseph’s Church

Office of Youth Ministry Office of Youth Ministry

73 Midline Road 45 MacArthur Dr

Ballston Lake, NY 12019 Scotia, NY 12302

Phone: 518-384-0109 x3 Phone: 518-374-3382

Email: Email:

RETREAT PERMISSION & MEDICAL CONSENT FORM

I, ______, the parent or guardian of ______,

(Name of parent/guardian) (Name of youth)

a youth at ______Parish, hereby grant permission for the above

youth to attend the Middle School Retreat on February 11th from 10-6pm at Our Lady of Grace Church with Grace Fay and I consent to his/her participation in this retreat. I understand that I am responsible for getting my youth to and from the retreat, but authorize that they may travel by car from the St. Joseph’s Parish Center to St. Joseph’s Church for the purposes of attending 4pm Mass, as part of the January 10thretreat.

I authorize the employees, representatives and chaperones of Our Lady of Grace and St. Joseph’s Churches to obtain emergency medical treatment, should it be necessary, during my child’s attendance and

participation in above program.

I understand that I will be notified immediately should it become necessary to obtain emergency treatment.

The person(s) who should be notified and the telephone number(s) are:

Name______Phone ______

Name ______Phone ______

I fully understand what is involved in this retreat, and I understand that I have the opportunity to call the

youth minister and ask him/her about this retreat.

In case of an emergency, I can be reached at ______.

MEDICAL INFORMATION (please type or print)

Allergies

______

Required medication (please indicate dosages, frequency, etc.) ______

______

Special Medical Conditions ______

Insurance Carrier: ______Policy Carrier: ______

Policy Number ______

Date of last tetanus booster ______

YOUTH AGREEMENT

I agree to abide by all rules and regulations decided upon by the parishes of Our Lady of Grace, St. Joseph’s, and the leadership personnel of the event. I understand that neither the parish ofOur Lady of Grace and St. Joseph’s, nor the leadership personnel of the event will be held liable if I fail tocooperate with said regulations and that any infraction of the rules may result in immediate dismissal fromthe event. I also understand and agree that I will notify my parent or guardian at the time of any violationsrequiring my dismissal from the program/activity and that I will be sent home at my own and/or parent’s/guardian’s expense.

______/_____/____

Signature of Youth Participant date

______/_____/_____

Signature of parent/guardian date