a-test - Holy Redeemer Catholic Parish

Youth Information

First Name *

Last Name *

Youth Cell Phone

Youth Email

Gender *

Male

Female

Age *

T-Shirt Size *

Does your child have any dietary requirements, medical history, medication, or major allergies? If yes, please indicate below:

Adult Information

Parent / Guardian / Emergency Contact (adult over 21)

Parent First Name *

Parent Last Name *

Phone *

Email *

Consent

CHECK THE BOXES BELOW *

I hereby authorize my son/daughter to attend the Fall Retreat. In case of emergency, I/we give permission to the attending, supervising adult from Holy Redeemer Parish to seek emergency treatment for my child. I/we grant permission for my child to participate in the Fall Retreat November 20-22, 2020. I understand that this activity will take place under the guidance and direction of Holy Redeemer Parish. I agree on behalf of myself, my child’s other parent or guardian, my child named herein, our heirs, successors, and assigns, to release, waive, indemnify and hold harmless and defend the parish, its employees and volunteers or other agents and the Archdiocese of St. Louis, and the officers, agents, representatives, volunteers and employees of the Archdiocese with respect to any and all actions, claims or demands that may be made or brought against the Archdiocesan Youth Office, its directors, employees and volunteers and the Archdiocese of St Louis. Medical Matters: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. Lost or Stolen Items: The Parish of Holy Redeemer and the Archdiocese of St. Louis will not be held liable for any valuables lost or stolen at the event described above. I understand and agree that this release is required as contractual consideration to the Archdiocese of St. Louis for allowing my daughter/son to participate in this event, and that my agreeing to this release of liability is a required prerequisite for the Archdiocese and Parish to allow my/our daughter/son to participate in the above described Parish event.

To the best of my knowledge, my child is in good health and has my/our permission to attend the Fall Retreat, November 20-22, 2020. In the event of circumstances which indicate that my child is in need of medical care, I/we authorize parish officials to consent to any necessary x-ray examination, medical or surgical diagnosis or treatment, and other evaluation, diagnosis, treatment, medication or hospital care in accordance with standard medical practice by licensed medical personnel. I/we release and agree to hold the parish harmless from any claims due to illness suffered by my child in the course of receiving such medical care and any consequences that may arise as the result of this treatment.

I grant permission to employees and agents of the school to give my child nonprescription drugs(e.g. Tylenol, Ibuprofen, etc.) in the event that circumstances reasonably demonstrate that my child is in need of such drugs.

I hereby give permission to the Archdiocese of St. Louis and Holy Redeemer Youth Ministry to use any photographs or video footage taken of my child in print, on their website, or on their social media channels for promotional purposes.

Signature *

Clear

Date Signed *

Printed Name of Parent or Guardian *

Payment

If you received a scholarship, please enter the code here

Payment Amount *

Credit Card *