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Saint Anne's Catholic Community

Saint Anne's Catholic Community

A Roman Catholic Church In Barrington, Illinois

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Catholic Heart Workcamp

Awaiting product image

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*
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.
MM slash DD slash YYYY
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.
MM slash DD slash YYYY

Teen's Information

Teen's Name*
MM slash DD slash YYYY
Teen's Address*

Parent/Guardian's Information

Parent/Guardian 1 Name*
Parent/Guardian 2 Name*

Emergency Contact Information

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

Physician and Health Information

Child’s Physician Name*

Insurance Information

Health Information

I give my permission for my child to receive email and text communication from Saint Anne Youth Ministry.*
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.*
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.
Teen's Printed Name*
MM slash DD slash YYYY
Parent's Printed Name*
MM slash DD slash YYYY
Important: Please watch your email for additional meeting and trip details as your teen’s Mission Trip date draws closer.
This field is for validation purposes and should be left unchanged.
Category: Uncategorized

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Address: 120 N. Ela Street • Barrington, IL 60010 Phone: (847) 382-5300
Fax: (847) 382-5363
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