Wild Sky HS - Youth :: St. Mary of the Expectation Catholic Church

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 of Birth REQUIRED Please fill out this field. Please enter a date.

Home Address REQUIRED Please fill out this field. Please enter valid data.

Home Address Line 2 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.

School Please enter valid data.

Current Grade REQUIRED

Grades 6-8 will attend the Expedition activities and grades 9-12 will attend the Brave Activities.

Please fill out this field.

Age (On Date of Event) REQUIRED Please fill out this field. Please enter an integer (number).

Sex REQUIRED Please fill out this field.

Roommate Request

Enter the names of other youth participants that your child would like to room with. Requests must be of the same gender.

T-shirt Size (Adult Sizes) REQUIRED Please fill out this field.

YOUTH PARTICIPANT: In signing the line below I agree to abide by any/all policies and rules established for this event. 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.

Electronic Signature (Youth Participant) REQUIRED

Must be completed by youth participant.

Please fill out this field. Please enter valid data.

Date of Signature REQUIRED Please fill out this field. Please enter a date.

Medical Matters
I hereby warrant 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 give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor.
In the event of an emergency and you are unable to reach me, contact:

Name of Emergency Contact REQUIRED Please fill out this field. Please enter valid data.

Relationship to Emergency Contact REQUIRED Please fill out this field. Please enter valid data.

Phone Number of Emergency Contact REQUIRED Please fill out this field. Please enter a phone number.

Name of Doctor Please enter valid data.

Phone Number of Doctor Please enter a phone number.

Medications
My child will bring all such medications, well labeled, that are necessary. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency are as follows:

My child is taking the following medications at the present time:

I hereby Grant Permission for nonprescription medication (such as Tylenol, Benadryl, throat lozenges, cough syrup, etc.) to be administered to my child if deemed advisable. ( REQUIRED Please fill out this field.

Initial REQUIRED Please fill out this field. Please enter valid data.

Medical Conditions Information: (Personnel will take reasonable care to see that the following information will be held in confidence.)
My son/daughter has:

Had an episode of the following or has been diagnosed:

Allergic reactions to the following (foods, dyes, medications, latex, etc.) Please enter valid data.

Has had a medical surgery within the last six months? Yes No

If yes, please describe the type of surgery. Please enter valid data.

If yes, still under doctor's care? Yes No

Has a medically prescribed diet? Please enter valid data.

The following physical limitations: Please enter valid data.

Immunizations current and up to date: REQUIRED Please fill out this field.

Date of last tetanus/diphtheria immunization Please enter a date.