St. Gregory Teen ACTS Retreat
June 19-22 2014
Application Form and Parental/Guardian Consent Form and Liability Waiver
Name: ______Name requested for Name Tag:______
Address: ______Zip Code: ______
Hm. Phone: ______Cell Phone: ______Other: ______
Grade: ______Age: ______Birthday: ______Shirt Size: Adult or Youth (circle one) _____
E-Mail:______
Parents/Guardian: ______Cell Phone: ______
Business Phone:______Cell Phone:______
Address (if different from above): ______Zip Code: ______
I, ______, grant permission for my child ______
to participate in this youth ministry event at the Antonian Retreat Center. This activity will take place under the guidance and direction of Mrs. Loraine Driskill, St. Gregory the Great Parishioner. A brief description of the activity follows:
Type of Event: Teen ACTS Retreat (Incoming High School Sophomores- Incoming High School Seniors)
Date of the Event: June 19-22, 2014
Activities: Interaction with youth and adults concerning religious, spiritual, moral, and social matters, prayer and scripture sharing and physical activities such as games and exercises
Cost: $150.00Deposit: $50.00 (Non-refundable) Remainder of balance due before retreat Payable to: St. Gregory Teen ACTS
Place of Event: Antonian Retreat Center 6425 West Avenue San Antonio, TX 78213
Estimated Time of Arrival at St. Gregory’s Parish Hall: Thursday, June 19 @ 5:45 pm
Estimated Time of Return: June 22 at10:00 Mass (at St. Gregory the Great Church)
Mode of Transportation to/from Event: Private Vehicles Provided by ACTS Core
As parent or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“participant”).
I agree on behalf of myself, my child named herein, our heirs, successors and assigns to hold harmless and defend St. Gregory Church, its officers, directors, and agents, and the Archdiocese of San Antonio from any and all liability for illness, injury or death arising from or in connection with my child’s personal actions at the above named event and I agree to compensate the parish, its officers and agents and the Archdiocese of San Antonio, or representative associated with the event for reasonable attorney’s fees and expenses arising in connection therewith.
Signature of Parent/Guardian: ______Date: ______
MEDICAL CONSENT AND PERMISSION TO TREAT
************** Please include a photocopy of your Insurance Card (front and back) ******************
To the best of my knowledge, my child, ______, is in good health, and I assume all responsibility for the health of my child.
Emergency Medical Treatment: In the event of an emergency, I hereby grant permission to transport my child to a hospital for emergency treatment _____ Yes _____ No
I wish to be advised prior to any further treatment by the hospital or doctor ____ Yes ____ No
Parent/Guardian: ______
Home Address: ______
Home Phone: ( ) ______Cell Phone: ( ) ______Business Phone: ( ) ______
If you are unable to reach me, please contact:
Name: ______
Relationship to me or my Child: ______
Home Phone: ( ) ______Cell Phone: ( ) ______Business Phone: ( ) ______
Family Doctor: ______Phone Number: ( ) ______
Insurance Carrier: ______Policy Number: ______
************** Please include a photocopy of your Insurance Card (front and back) ******************
My child is taking medication and will bring all medication with him/her. It will be clearly labeled. My child is taking the following medication(s) and directions for taking this medication, including dosage, frequency and storage is as follows: ______.
I hereby grant permission for non-prescription medication (such as cough drops, cough syrup, Tylenol, etc.) to be given to my child if necessary: ____ Yes ____ No
I understand that aspirin will not be given to my child without my expressed permission. I hereby grant such permission: ____ Yes ____ No
My child is allergic to the following (medications, foods, plants, insects, etc.) ______
______
My child’s immunization record is current and up to date: ____ Yes ____No
My child’s last tetanus shot was ______
My child has the following physical limitation ______
My child experiences homesickness emotional reactions to new situations sleepwalking fainting
other: ______Yes ____ No
My child has recently been exposed to a contagious disease or condition such as mumps, measles, chickenpox, etc. ______Yes ____ No If Yes, please state the disease and date or condition:
______
My child is suffering from a psychological condition, which may affect or limit his or her ability to participate in this activity. ____ Yes ____ No If Yes, please explain:______
Signature of Parent or Guardian: ______Date: ______
Turn in registration forms into the rectory in an envelope addressed to Mrs. Driskill