Name: Catholic Heart Workcamp
SKU: 25689
Availability: InStock

Parent/Guardian Permission Form and Waiver for Catholic Heart Workcamp

THIS FORM MUST BE COMPLETED FOR EVERY YOUTH PLANNING TO ATTEND
NOTE: We do not accept American Express

10 in stock

"*" indicates required fields

Teen's Name*

First Last

Parental/Guardian Permission & Authorization to Attend*

I hereby give permission for my child (named above) to participate in the Catholic Heart Workcamp on June 11-16, 2023, to be held in Louisville, KY, overnight accommodations at Highland Hills Middle School 3492 Edwardsville-Galena Road, Georgetown, IN 47122, and sponsored by Saint Anne Catholic Community, Barrington, IL. I understand that my child will be transported to/from the campus by bus and/or van and off-campus each day to their work site and back, possibly under the supervision of an adult from another parish.

Liability Release:
 I hereby release and indemnify Saint Anne Catholic Community, The Archdiocese of Chicago, and The Office for Catechesis and Youth Ministry of the Archdiocese of Chicago, its staff and volunteers and the Catholic Bishop of Chicago, a corporate sole, from any and all liability arising from claims of any kind or nature whatsoever relating to my child’s participation in this event.

I agree

Parent Signature*

Date*

Medical/Emergency Treatment Authorization:*

In the event that the undersigned parent/guardian cannot be reached, and in the judgment of the responsible adults or other appropriate staff members accompanying the group, if there is a necessity for immediate examination and/or treatment of my child, I hereby authorize any of the aforesaid personnel to obtain for my child such medical services as are deemed necessary.

I agree

Parent Signature*

Date*

Teen's Information

Teen's Name*

First Last

Teen’s High School*

Year of HS Graduation*

T-Shirt Size*

Teen's Date of Birth*

Teen’s Home Church*

Teen's Email*

Teen's Cell Phone*

Teen's Address*

Address City State Zip

Parent/Guardian's Information

Parent/Guardian 1 Name*

First Last

Parent/Guardian 1 Cell Phone*

Parent/Guardian 1 Email*

Parent/Guardian 2 Name*

First Last

Parent/Guardian 2 Cell Phone*

Parent/Guardian 2 Email*

Emergency Contact Information

Emergency Contact*

In the event that the above parent(s)/guardian(s) cannot be reached

First Last

Emergency Contact Phone*

Emergency Contact Email*

Relationship to Child*

Physician and Health Information

Child’s Physician Name*

First Last

Child’s Physician Phone*

Insurance Information

Policy in the Name of*

Insurance Company*

Insurance Policy Number*

Insurance ID Number*

Health Information

Allergies/Dietary Restrictions*

Current Medications*

Any Additional Information You’d Like Us To Know*

I give my permission for my child to receive email and text communication from Saint Anne Youth Ministry.*

Yes

I give my permission for my child to be photographed/videoed while both preparing for and on this trip for possible use in website/bulletin/social media advertising by Saint Anne Youth Ministries.*

Yes

Mission Trip Code of Conduct:*

Rules of Behavior for Students
- Attend all scheduled activities
- Will not smoke or engage in the use of alcohol or drugs or have them in my possession
- Will treat all staff, chaperones and fellow participants with respect at all times
- Will treat the facilities and grounds with respect at all times
- Will abide by any and all additional rules expressed by the chaperones or facility staff

Consequences of Not Abiding by the Rules
- For behavioral infractions or breaking of rules, warning will be given and the participant will have the opportunity to change the problematic behavior. If the problematic behavior continues, the participant will be asked to contact their parents to arrange to return home immediately.
- If the participant brings alcohol or drugs, the participant will be asked to contact their parents to arrange to return home immediately.
- If the participant uses alcohol or drugs during the event, even if they are not the one to bring them, they will be asked to contact their parents to arrange to return home immediately.

I have read the above Rules of Behavior and Consequences of Not Abiding by the Rules governing this event. I understand that if my child violates any rules governing the event, I will be called and notified of the situation and will be asked to arrange to have my child sent home immediately at my expense. I understand that I am fully responsible for any damages that may occur as a result of the actions of the subject of this agreement and that neither Saint Anne, nor any of its agents will be held liable.

I agree

Teen's Printed Name*

First Last

Teen's Signature*

Date*

Parent's Printed Name*

First Last

Parent's Signature*

Date*

Important: Please watch your email for additional meeting and trip details as your teen’s Mission Trip date draws closer.

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