Please Turn in Form to Anniekubek Or Mac Clapp By

Page 1 of 3

***Please turn in form to AnnieKubek or Mac Clapp by:

March 8, 2018 by 5:00pm****

Dear Youth Coordinator:

As the Parent/Guardian of ______, a

(Student’s name)

participant in the Our Lady retreat lock-in, I hereby request permission for the above named child/children to attend the Our Lady Teen Retreat lock-in and I consent to the child’s participation in the retreat lock-in. I understand that I must provide transportation to and from the Church (Our Lady of Perpetual Help Church) for my child. I hereby assume all risks in connection with the youth retreat lock-in and I further release discharge, and/or otherwise indemnity the Diocese of Youngstown, the Bishop of the Roman Catholic Diocese of Youngstown, Our Lady of Perpetual Help Parish, employees and volunteers from all claims, judgments, liability by or on behalf of my child, myself and my spouse for any injury or damage due to the child’s participation in the youth retreat including all risks connected therewith whether foreseen or unforeseen. Furthermore, I acknowledge that it is my responsibility to provide adequate health insurance for my child/children. I understand I have the opportunity to call Annie Kubek at (330) 840-0131 /or Mac Clapp at (330) 562-8519 (x121)about the youth retreat lock-in.

Signature of parent/guardian: ______

Teen’s Name ______Age ______Gr______

Address: ______

City______Zip______

Parent(s)Name______

Parent cell phone_(______)______-______

Parent’s email______

Teen’s Cell (______)______-______

Home Phone Number (______)______-______

Food Allergies ______

Vegetarian (Please check yes or no) YES______NO______

My teenager’s photograph can be taken and used for different events and videos pertaining to Our Lady Youth Ministry.(Please check yes or no) YES______NO______

Signature______

*****Continuation of form on back*******

MEDICAL RELEASE

(Please check and sign only those in accordance with your wishes.)

In the event of an emergency, I hereby grant permission to transport my son/daughter and obtain emergency medical or surgical treatment from a licensed physician, hospital, or medical clinic. I hereby authorize medical personnel to release necessary information about my care to Annie Kubek and Mac Clapp as parish group leaders(s) I wish to be advised prior to further treatment by the hospital or doctor. In the event I cannot be reached, please

contact______at______

Relationship to youth ______

Family physician ______Phone: ______

(Please check one of the following)

My son/daughter is covered by hospitalization and medical insurance under

policy#______issued by______

My son/daughter does not have medical coverage and I assume responsibility for the cost of hospitalization and medical care for my son/daughter.

Signature: ______Date: ______

I hereby warrant that to the best of my knowledge, my son/daughter is in good health. I do not want any medical treatment to be given to my son/daughter under any circumstances. I hereby assume all responsibility for the health and well-being of my son/daughter and release from responsibility the Bishop of the

Diocese of Youngstown, and Our Lady of Perpetual Help parish, and the agents, associates, and employees of the Bishop and parish who have organized or participated in the supervision of such program.

Signature: ______Date: ______

My son/daughter is taking medications at present. He/she will bring all such medications necessary and such medications will be well labeled. The names of, and concise directions for taking such medications, including dosage and frequency of dosage are as follows. ______

Signature: ______Date: ______

No medication of any type whether prescription or nonprescription may be administered to my child unless the situation is life threatening and emergency treatment is required.

Signature: ______Date: ______

I hereby grant permission for nonprescription medication (such as acetaminophen, decongestant, cough syrup) to be given to my son/daughter, if requested by my son/daughter and deemed advisable by an adult chaperone.

Signature: ______Date: ______

I wish to inform you of the following additional medical information and the recommended course of action (allergies, dietary restrictions, special conditions, etc.)

Signature: ______Date: ______