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LT Fall Retreat Youth Registration

- The maximum number of form submissions has been reached. This form is currently not available.
  
  Parent/Guardian 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.
  
  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.
  
  Parent/Guardian 2
  
  First Name Please enter valid data.
  
  Last Name Please enter valid data.
  
  Phone Number Maximum 20 characters Please enter a phone number.
  
  Email Please enter an email address.
  
  Number of Children Registering REQUIRED
  **Must be child's legal guardian to register**
  Please fill out this field.
  
  Child 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.
  
  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.
  
  Grade (On Date of Event) REQUIRED
  Enter the child's grade on the date of the event.
  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.
  
  T-Shirt Size 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 Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Name of Doctor Please enter valid data.
  
  Phone Number of Doctor Maximum 20 characters 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: Yes No
  
  Allergic reactions to the following (foods, dyes, medications, latex, etc.) Please enter valid data.
  
  Has had a medical surgery within the last six months? REQUIRED Yes No Please fill out this field.
  
  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.
  
  Child 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.
  
  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.
  
  Grade (On Date of Event) REQUIRED
  Enter the child's grade on the date of the event.
  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.
  
  T-Shirt Size 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 Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Name of Doctor Please enter valid data.
  
  Phone Number of Doctor Maximum 20 characters 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: Yes No
  
  Allergic reactions to the following (foods, dyes, medications, latex, etc.) Please enter valid data.
  
  Has had a medical surgery within the last six months? REQUIRED Yes No Please fill out this field.
  
  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.
  
  Child 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.
  
  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.
  
  Grade (On Date of Event) REQUIRED
  Enter the child's grade on the date of the event.
  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.
  
  T-Shirt Size 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 Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Name of Doctor Please enter valid data.
  
  Phone Number of Doctor Maximum 20 characters 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: Yes No
  
  Allergic reactions to the following (foods, dyes, medications, latex, etc.) Please enter valid data.
  
  Has had a medical surgery within the last six months? REQUIRED Yes No Please fill out this field.
  
  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.
  
  Child 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.
  
  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.
  
  Grade (On Date of Event) REQUIRED
  Enter the child's grade on the date of the event.
  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.
  
  T-Shirt Size 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 Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Name of Doctor Please enter valid data.
  
  Phone Number of Doctor Maximum 20 characters 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: Yes No
  
  Allergic reactions to the following (foods, dyes, medications, latex, etc.) Please enter valid data.
  
  Has had a medical surgery within the last six months? REQUIRED Yes No Please fill out this field.
  
  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.
  
  You should also be aware of these special medical and/or psychological conditions of my child (e.g. depression, A.D.D., etc):
  
  Consent and Liability Waiver
  
  Important! To be filled out by the Parent/Guardian for youth under 18 years of age. (If participant is 18 years of age or older, consent must be signed by the individual)
  
  I (name of parent/guardian), REQUIRED Please fill out this field. Please enter valid data.
  
  grant permission for my child, (participant's name), REQUIRED Please fill out this field. Please enter valid data.
  
  to participate in St. Mary of the Expectation's  Life Teen Fall Retreat to be held on Saturday, December 14, 2024 at St. Mary of the Expectation Catholic Church.
  
  I agree on behalf of myself, my child’s other parent/guardian if known or living,
  
  (name of other parent) REQUIRED Please fill out this field. Please enter valid data.
  
  my child name herein, or our heirs, successors, and assigns and defend the Archdiocese of Galveston-Houston, the sponsoring parish (its pastor, youth ministry leader, principal, other agents, etc.) or any representatives associated with the scheduled activity unless the parties involved were careless and negligent.
  
  In signing this form I certify that all information contained herein is true and accurate to the best of my knowledge.
  
  Date of Signature REQUIRED Please fill out this field. Please enter a date.
  
  Electronic Signature (Parent/Guardian) REQUIRED Please fill out this field. Please enter valid data.
  
  Video/Photography Consent
  
  As parent/guardian, I understand that promotional pictures and videos (individual and group) will be taken during this event. I give permission for my son’s/daughter’s picture to be used for promotional materials (newsletter, web page, calendars, power point, video, etc.) in highlighting the event.
  
  Electronic Signature (Parent/Guardian) REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Signature REQUIRED Please fill out this field. Please enter a date.
  
  Insurance Information
  
  Does your child have medical insurance coverage at this time? REQUIRED Please fill out this field.
  
  Insurance Carrier Please enter valid data.
  
  Name of Insured Please enter valid data.
  
  Insurance Policy Number Please enter valid data.
  
  Insurance Group Number Please enter valid data.
  
  Father's Name REQUIRED Please fill out this field. Please enter valid data.
  
  Father's Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Mother's Name REQUIRED Please fill out this field. Please enter valid data.
  
  Mother's Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  In the event it comes to the attention of the chaperones associated with the activity that my child becomes ill with repeated symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called immediately. If this will be a long distance call, I want to be called collect (with phone charges reversed to myself). I fully understand the foregoing statements and sign this Parental/Guardian Medical Consent Waiver knowingly, freely, and willingly.
  
  Electronic Signature REQUIRED
  Signature (Parent/Guardian must sign for anyone under 18 years of age)
  Please fill out this field. Please enter valid data.
  
  Date of Signature REQUIRED Please fill out this field. Please enter a date.
  
  Registration Fee50.0
  
  Processing Fee2.0
  
  Total:
  
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- Contact Us
  
  David Harley
  
  Director of Youth Ministry
  
  281-332-3031 ext. 116
  david.harleysaintmcc.org