2022 Fall Retreat Permission Form

DIOCESE OF COLUMBUS
REGISTRATION/PERMISSION/RELEASE AND INDEMNIFICATION AGREEMENT

PARISH NAME(S): St. Peter & St. Mary
PARISH CITY: Chillicothe, OH
NAME OF ADULT LEADER: Andrea McLean [email protected] // 740-701-2654
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ACTIVITY: 2022 Youth Group Fall Retreat
LOCATION: Damascus Catholic Mission Campus
7550 Ramey Rd., Chillicothe, OH 43011
DATES: Friday, October 28th @ 6pm - Sunday, October 30th @ 3pm
TRANSPORTATION: Parent Coordinated

Youth Participants REQUIRED Please fill out this field.
Registration 1
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthday REQUIRED Please fill out this field. Please enter a date.
- Sex REQUIRED Male Female Please fill out this field.
- Phone Number Maximum 20 characters Please enter a phone number.
- A. SPECIFIC MEDICAL INFORMATION: The Parish will take reasonable care to see that the following information will be held in confidence.
- Chronic Conditions (e.g. Epilepsy; Diabetes) Please enter valid data.
- Allergic Reactions (e.g. Food, medications, plants, etc.) Please enter valid data.
- Dietary Restrictions Please enter valid data.
- Immunizations: Date of last tetanus/diphtheria immunization: Please enter a date.
- Any physical limitations? Please enter valid data.
- Has the Participant recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? If so, list date and disease or condition: Please enter valid data.
- You should be aware of these special medical conditions of the Participant: Please enter valid data.
- B. CURRENT MEDICATION: The Participant is taking medication at present. The Participant will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows:
- Directions for medications:
- C. NON-PERSCRIPTION MEDICATION
- Please Choose ONE of the following: REQUIRED Non-prescription medication may be given to the Participant, if deemed appropriate such as: Advil, Tylenol, or Benadryl No medication of any type, whether prescription or non-prescription, may be administered to the participant unless the situation is life-threatening and emergency treatment is required. Please fill out this field.
Registration 2
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthday REQUIRED Please fill out this field. Please enter a date.
- Sex REQUIRED Male Female Please fill out this field.
- Phone Number Maximum 20 characters Please enter a phone number.
- A. SPECIFIC MEDICAL INFORMATION: The Parish will take reasonable care to see that the following information will be held in confidence.
- Chronic Conditions (e.g. Epilepsy; Diabetes) Please enter valid data.
- Allergic Reactions (e.g. Food, medications, plants, etc.) Please enter valid data.
- Dietary Restrictions Please enter valid data.
- Immunizations: Date of last tetanus/diphtheria immunization: Please enter a date.
- Any physical limitations? Please enter valid data.
- Has the Participant recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? If so, list date and disease or condition: Please enter valid data.
- You should be aware of these special medical conditions of the Participant: Please enter valid data.
- B. CURRENT MEDICATION: The Participant is taking medication at present. The Participant will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows:
- Directions for medications:
- C. NON-PERSCRIPTION MEDICATION
- Please Choose ONE of the following: REQUIRED Non-prescription medication may be given to the Participant, if deemed appropriate such as: Advil, Tylenol, or Benadryl No medication of any type, whether prescription or non-prescription, may be administered to the participant unless the situation is life-threatening and emergency treatment is required. Please fill out this field.
Registration 3
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthday REQUIRED Please fill out this field. Please enter a date.
- Sex REQUIRED Male Female Please fill out this field.
- Phone Number Maximum 20 characters Please enter a phone number.
- A. SPECIFIC MEDICAL INFORMATION: The Parish will take reasonable care to see that the following information will be held in confidence.
- Chronic Conditions (e.g. Epilepsy; Diabetes) Please enter valid data.
- Allergic Reactions (e.g. Food, medications, plants, etc.) Please enter valid data.
- Dietary Restrictions Please enter valid data.
- Immunizations: Date of last tetanus/diphtheria immunization: Please enter a date.
- Any physical limitations? Please enter valid data.
- Has the Participant recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? If so, list date and disease or condition: Please enter valid data.
- You should be aware of these special medical conditions of the Participant: Please enter valid data.
- B. CURRENT MEDICATION: The Participant is taking medication at present. The Participant will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows:
- Directions for medications:
- C. NON-PERSCRIPTION MEDICATION
- Please Choose ONE of the following: REQUIRED Non-prescription medication may be given to the Participant, if deemed appropriate such as: Advil, Tylenol, or Benadryl No medication of any type, whether prescription or non-prescription, may be administered to the participant unless the situation is life-threatening and emergency treatment is required. Please fill out this field.
Registration 4
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Birthday REQUIRED Please fill out this field. Please enter a date.
- Sex REQUIRED Male Female Please fill out this field.
- Phone Number Maximum 20 characters Please enter a phone number.
- A. SPECIFIC MEDICAL INFORMATION: The Parish will take reasonable care to see that the following information will be held in confidence.
- Chronic Conditions (e.g. Epilepsy; Diabetes) Please enter valid data.
- Allergic Reactions (e.g. Food, medications, plants, etc.) Please enter valid data.
- Dietary Restrictions Please enter valid data.
- Immunizations: Date of last tetanus/diphtheria immunization: Please enter a date.
- Any physical limitations? Please enter valid data.
- Has the Participant recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? If so, list date and disease or condition: Please enter valid data.
- You should be aware of these special medical conditions of the Participant: Please enter valid data.
- B. CURRENT MEDICATION: The Participant is taking medication at present. The Participant will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows:
- Directions for medications:
- C. NON-PERSCRIPTION MEDICATION
- Please Choose ONE of the following: REQUIRED Non-prescription medication may be given to the Participant, if deemed appropriate such as: Advil, Tylenol, or Benadryl No medication of any type, whether prescription or non-prescription, may be administered to the participant unless the situation is life-threatening and emergency treatment is required. Please fill out this field.

EMERGENCY MEDICAL CONTACT AND TREATMENT

Guardian Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Address REQUIRED Please fill out this field. Please enter valid data.
City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Email REQUIRED Please fill out this field. Please enter an email address.
EMERGENCY CONTACT
If I as a parent/guardian cannot be reached at the above number, contact:
First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Relationship to Youth Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Emergency Medical Treatment

In the event of an emergency, the undersigned hereby give(s) permission to transport the Participant to a hospital for emergency medical or surgical treatment. The undersigned wish(es) to be advised prior to any further treatment by the hospital or doctor.
I Agree Please select this field.
Signature REQUIRED Please fill out this field. Please enter valid data.

Medical Insurance Information

Medical Insurance Provider REQUIRED Please fill out this field. Please enter valid data.
Insurance Provider Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Member's Name REQUIRED Please fill out this field. Please enter valid data.
Policy Number REQUIRED Please fill out this field. Please enter valid data.
Family Doctor REQUIRED Please fill out this field. Please enter valid data.
Family Doctor Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.

Permission and Release Forms

PERMISSION
The undersigned hereby state(s) that (he/she/they) (is/are) the (parent/parents/guardian) of the above named Participant and have full legal responsibility for the Participant. The undersigned hereby grant(s) permission for the Participant to participate in the Activity named in Section above.

RELEASE AND INDEMNIFICATION
1. Release. The undersigned on behalf of the undersigned, the Participant, and the heirs, successors and assigns of the undersigned and the
  
  Participant, hereby release, hold harmless from any liability, and discharge from all direct or derivative claims, actions, causes of actions, medical expenses, costs, legal expenses, other expenses and all other damages at law or in equity, known or unknown, direct or indirect, choate or inchoate against the Diocese of Columbus, the Parish and all current and former employees, agents, clergy, officers and volunteers of the Diocese of the Parish, arising from the Participant’s participation in the Activity named in Section I.B., above.
2. Indemnification. The undersigned shall indemnify and hold harmless the Diocese of Columbus, the Parish, and all current and former employees, agents, clergy, officers and volunteers of the Diocese of Columbus or the Parish from any claim, liability, suit, judgment, loss, damage, expense, fee or cost (including court costs and attorney fees) arising directly or indirectly from the Participant’s participation in the Activity named in Section I.B., above, unless arising from the negligence of an indemnified party.
CONSENT FOR RELEASE OF PERSONALLY IDENTIFIABLE INFORMATION

The undersigned hereby consent to the release of photographs and name of the Participant to be used by the Diocese of Columbus and St. Peter and St. Mary Church for future promotional programs of the Diocese and Parish. If you have any questions or concerns, please contact Andrea McLean (Parish Point of Contact) at 740-701-2654
Please choose an option below REQUIRED I consent to release of personally identifiable information I DO NOT consent to release of personally identifiable information Please fill out this field.

Code of Behavior

The Participant shall comply with the following:
1. The Participant must stay and participate in the entire event. The Participant may not leave the premises unless accompanied by an adult leader, parent, or legal guardian.
2. The possession or use of alcohol, tobacco, drugs, or weapons of any kind is not permitted.
3. Foul language is not tolerated.
4. The Participant must comply with any and all directions of activity staff.
5. The Participant must respect the rights and property of others. Damage to or defacing of property will be the financial responsibility of
  
  the Participant involved and the undersigned.
6. Failure to abide by this Code of Behavior may result in a request to the undersigned to transport the offending Participant from the
  
  premises, and the undersigned shall immediately comply with the request.

Youth Participants REQUIRED Please fill out this field.
Signatures of Youth Participant(s) 1
- I have read and agree to follow the Code of Behavior set forth by the Diocese of Columbus.
  I Agree Please select this field.
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.
Signatures of Youth Participant(s) 2
- I have read and agree to follow the Code of Behavior set forth by the Diocese of Columbus.
  I Agree Please select this field.
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.
Signatures of Youth Participant(s) 3
- I have read and agree to follow the Code of Behavior set forth by the Diocese of Columbus.
  I Agree Please select this field.
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.
Signatures of Youth Participant(s) 4
- I have read and agree to follow the Code of Behavior set forth by the Diocese of Columbus.
  I Agree Please select this field.
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.

Parent/ Guardian Signature

THE UNDERSIGNED HAS READ, UNDERSTANDS AND HEREBY AGREES TO AND ACCEPTS ALL PROVISIONS IN THIS AGREEMENT
I Agree Please select this field.
First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Date REQUIRED Please fill out this field. Please enter a date.