Middle School Vacation

June 17-21, 2013
Departure from Nativity at 9:00am on June 17
Return to Nativity at 3:00pm on June 21

Franciscan Retreat Center
7740 Deer Hill Grove
Colorado Springs, CO 80919

Fee: $400

Step 1 of 4

25%

Name of Minor ("Participant")*
Address*
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry
Home Phone*
Cell Phone
Email*
Parent(s)/Guardian(s) Name(s)*

Parent Approval
I/we grant permission for my/our child to participate in this Faith Alive High School Retreat. This retreat will take place under the guidance and direction of clergy, employees and/or volunteers of Nativity of Our Lord Catholic Parish, Broomfield, Colorado from 9:00am, June 17th through 3:00pm, June 21st at Franciscan Retreat Center in Colorado Springs.

Mode of Transportation: Buses
Information*
- I understand that me and my child’s information may be used and seen by Nativity staff, volunteers, and other coordinators and participants of this event.
Photo Release*
- I authorize Nativity of Our Lord to publish photographs taken of my child at this retreat for use in online, print, and/or video publications.
As parent(s) and/or legal guardian(s), I/we remain legally responsible for any personal actions taken by the above-named Participant. I/We further agree to defend, indemnify and hold harmless Nativity of Our Lord Catholic Parish, Broomfield, CO as well as any of its affiliated agencies and their respective agents, directors, officers, employees, and volunteers from any and all claims or demands made for damage, loss, illness or injury to the above-named Participant.
Parent(s)/Guardian(s) Signature(s)*
Signature Date

NOTE: By typing your name in the signature field, you are signing this agreement electronically, which is as legally binding as a regular signature.

Medical Matters
Nativity of Our Lord will take all reasonable and prudent care to see that confidentiality regarding the following information is maintained. I/We hereby warrant that to the best of my/our knowledge, my/our child is in good health, and I/ we assume all responsibility for the health of my/our child. I/We understand and acknowledge that any medical expenses related to illness or injury to my/our child are not covered by any insurance program maintained by the Nativity Of Our Lord Parish, and that I/we am/are responsible for such expenses. Emergency Medical Treatment: In the event of an emergency, I/we hereby give permission to transport my/our child to a hospital for emergency medical or surgical treatment. I/we wish to be advised prior to any further treatment by the hospital or doctor.
In the event of an emergency, if you are unable to reach me/us at the above numbers, contact:*
Name of Minor ("Participant")*
Sex*
Birthdate*
Emergency Phone*
Family Doctor*
Phone*
Family Health Plan Carrier*
Policy #*
Allergic reactions (medications, foods, plants, insects, etc.)*
Date of last tetanus/flu immunization*
Does participant have a medically prescribed diet?*
Any physical limitations?*
Other special medical conditions*
Is participant taking medication at present?*
It is participant’s responsibility to bring all necessary medications, and to ensure they are clearly labeled. Instructions from the participant’s family physician for these medications must be attached to this form. The instructions must include the name, concise dosing directions, purpose of, and proper storage of and for all medications.

NOTE: Parish staff and volunteers WILL NOT administer ANY medications requiring the use of a syringe or other needle delivery system. Alternate accommodations for must be made for these circumstances and the parish fully informed of the nature of such accommodations.
I/We want to be contacted in the event it comes to the attention of the parish, its officers, directors and agents, chaperones, or representatives associated with the activity that Participant experiences symptoms such as headache, vomiting, sore throat, fever, diarrhea, etc.*
I/We hereby grant permission for the following non-prescription medication (non-aspirin products such as acetaminophen or ibuprofen, throat lozenges, cough syrup, etc.) to be administered to the Participant, if deemed appropriate.
OR: No medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life-threatening and emergency treatment is required.
Parent(s)/Guardian(s) Signature(s)*
Signature Date

NOTE: By typing your name in the signature field, you are signing this agreement electronically, which is as legally binding as a regular signature.

Additional Information
Please select one of the following:*
- A. I am able to be a chaperone for the entire vacation.
- B. I am able to be a chaperone for a portion of the vacation.
- C. I am not able to be a chaperone for the vacation.
If you selected option B, please note your availability here:
Answer only if you selected option A or B: Have you completed Safe Environment Training?

Middle School Vacation

Middle School Vacation

Step 1 of 4

Parent Approval

Medical Matters

Additional Information