Parental consent and emergency medical release form
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| Catholic Archdiocese of Atlanta
ST. BRENDAN THE NAVIGATOR THE NAVIGATOR PARENTAL CONSENT AND EMERGENCY MEDICAL RELEASE FORMANTIOCH RETREAT Camp High Harbor, 40 Old Sandtown Road (Lake Altoona), Cartersville, GA 30121 November 9-11 2012 $115 retreatants/$95 Core Team teens I/We, the parent(s)/guardian(s) of_________________________________________________________ do hereby give my/our permission and approval for my/our son/daughter/guardianship to participate on the (Antioch Retreat) on (November 9-11, 2011), with the ST. BRENDAN THE NAVIGATOR Youth Group. I/ We do hereby, for myself, my heirs, executors, and administrators, waive, release, absolve, indemnify and agree to hold harmless any and all adults who chaperone this event, other participants, ST. BRENDAN THE NAVIGATOR, the Catholic Archdiocese of Atlanta, (Antioch Retreat / Camp High Harbor, Lake Altoona), and any of the above named parties’ representatives, successors, supervisors, sponsors, and/or organizers, for any injuries in connection with the outing / event(s) named above provided that said injuries are not the result of negligence. I/We hereby grant permission for publication of group (two or more persons) photos taken at youth events. I/We also give permission to seek any emergency care should my child be involved in any accident or be injured in any way during such events named above. I/We understand that in any such instance, all attempts will be made to contact the parent/guardian. In the event that I/we cannot be contacted, I/we hereby give permission to the attending physician to hospitalize, secure treatment for, and to order injection, anesthesia, and/or surgery for my child, as named herein. I also agree that I am legally responsible for all/any personal actions taken by my child/guardianship during this event, and agree to be financially responsible for any/all damages, legal fees, and other costs incurred as a result of the actions/behavior of my child/guardianship. Furthermore, I/we agree that if the above named student’s behavior is inappropriate, unsafe and/or detrimental to the group, I will be contacted immediately to secure means of removing my child/guardianship from the event premises. I understand that any financial costs incurred as a result of my child/guardianship being sent home are my responsibility. TRANSPORTATION IS BY VOLUNTEER CARPOOL: WE NEED PARENTAL SUPPORT: ______YES , I CAN DRIVE. I HAVE _______SEATBELTS. Can drive Friday/Sunday (circle days) ---------- YES/NO: I HAVE A CURRENT BACKGROUND CHECK/MOTOR VEHICLE REPORT Name of Student: _______________________________________________ Date of Birth:_________________ Name of High School _____________________________________ T-Shirt Size _________________________ Address:_____________________________________________________________________________________ ___________________________________________ Parent Email: ____________________________________ Cell phone #:______________________________ Please list any special considerations we need to be aware of (ie: allergies, medical conditions, limitations, etc...) _______________________________________________________________________________________________ Medications: My child is taking the following medication(s): Description _______________________________________ Dosage ________________________ Description _______________________________________ Dosage ________________________ (EITHER A PHYSICIAN’S PRESCRIPTION OR PARENT NOTE MUST ACCOMPANY ALL MEDICATIONS, PRESCRIPTION / NOTE SHOULD BE ATTACHED TO THIS FORM.) ______By parent or guardian initialing here, permission is granted for non-prescription medications to be given, if deemed appropriate by adult chaperone(s). Requested information on both sides of this form MUST be filled in completely in order for the student to participate in this event Father/Guardian’s full name:__________________________________________________________________ Phone #:______________________________ Cell # ________________________________________ Home address:_______________________________________________________________________________ Place of business/address:_____________________________________________________________________ Mother/Guardian’s full name:_________________________________________________________________ Phone #:______________________________ Cell # ________________________________________ Home address:_______________________________________________________________________________ Place of business/address:_____________________________________________________________________ Relative or friend to contact if unable to reach parent/guardian in the event of emergency: Name & Relationship:___________________________________________________________________________ Phone #:_______________________________________________________________________________________ Insurance Carrier:______________________________________________________________________________ Insurance Policy Number:________________________________________________________________________ Insurance is provided by which parent and/or place of employment? ___________________________________ Address and Phone Number of Company:___________________________________________________________ **Please photocopy insurance card that is to be used and attach it to this form** Parent/Guardian signature:___________________________________________________Date:_______________ Printed Name:________________________________________ Relationship: ______________________________ Name of Parish: St. Brendan the Navigator Name of Youth Minister: Lisa Lively In signing this form, I certify that all information contained herein is true and accurate to the best of my knowledge. ******************************************************************************************** Participant (Student) Signature: __________________________________________ Date: ___________________ In signing the above line, I agree to abide by any / all policies and rules established for this event / activity. Should I not be able to maintain the guidelines and expectations of the adults and my peers, I understand that there will be consequences for my actions, including being removed from the activity and being sent home at my parent’s expense. No Phones or Electronic Devices Permitted Basic rules / expectations include, but are not limited to, the following: Respect for all adult leaders, peers, and all property; NO illegal drugs, alcohol, underage smoking, firearms, explosives, or other illegal substances; Males and females are to remain in separate sleeping spaces at all times; No inappropriate physical / sexual activity; Appropriate attire is to be worn at all times. Other guidelines may be set forth accordingly by adult chaperones present for the event(s). Instructions, Information and Supply List Antioch Retreat 2012 Camp High Harbour at Lake Altoona 40 Old Sandtown Road Cartersville, GA 30121 Retreat Coordinator: Wendy Paxton / 404-932-2681 Youth Minister: Lisa Lively: 770-205-7969 Cost: $115.00 Retreatants Core Team Teen $ 95.00 per teen Adult Chaperone $ 50.00 per adult Adult Chaperone Couples $75 per couple TRANSPORATION WILL BE PROVIDED BY ASSIGNED CARPOOLS WE NEED VOLUNTEERS!! _____YES I CAN DRIVE FRIDAY/SUNDAY (PLEASE CIRCLE CHOICE Permission Slips, copy of insurance and payment are due NO LATER THAN October 22,2012. Please make checks payable to St. Brendan YMCA of Metro Atlanta Release Waiver, Indemnification and Health Affirmation must be completed and submitted along with St. Brendan Permission Slip, copy of insurance and payment information. Your teen needs to be at the Social Hall by 5:45pm Please be sure to eat dinner before arrival Arrival Camp High Harbor 7:00pm Friday, November 11 Retreat Concludes Sunday, November 13 after 5:00PM Mass Please, Please, Cell phones and electronics’ need to stay at home!! You may call your teen via my cell. Ensure we have the most current and up to date contact and emergency contact information on the permission slip!!
And towels. Temperatures vary..bring sweaters/jackets for outside,sneakers A donation of a snack to share. All questions please call me at 404-932-2681 or email me at wpaxton@stbrendanatl.com Looking forward to a great weekend with your teen! Wendy Paxton Retreat Coordinator Directory: wp-content -> uploads -> 2012 2012 -> The Case Against the nypd’s Quota-Driven ‘Broken Windows’ Policing What Is It? 2012 -> Aa and na members Dying from Tobacco 2012 -> [Baby Crying] 01: 04 [Ching 2012 -> Unit Name / Nom de l’unité uic / ciu dates 2012 -> What We Owe Jehovah’s Witnesses 2012 -> Oceans Challenge Badge 2012 -> Canadian cycling olympians 2012 -> Greg landry, june olkowski and tom lysiak 2012 -> William goldman 2012 -> Does translocation and restocking confer any benefit to the European eel population? A review Download 24.67 Kb. Share with your friends:
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