Parent/Guardian Permission Form for High School Confirmation Retreat This form must be completed for every youth planning to attend "*" indicates required fields Child's Name First Last Parental/Guardian Permission & Authorization to Attend*I hereby give permission for my son/daughter (named above) to participate in the Spiritus Retreat on January 23, 2022 or January 30, 2022 at Bellarmine Jesuit Retreat Center, 420 West County Line Road, Barrington, IL, sponsored by Saint Anne. 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 understand that if my child violates any laws regarding possession of alcohol or drugs, or 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 agreeMedical AuthorizationsIn 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. Emergency Contact InformationEmergency Contact*In the event that the above parent(s)/guardian(s) cannot be reached First Last Emergency Contact Phone*Relationship to Child* Child’s Physician Name* First Last Child’s Physician Phone*Insurance InformationPolicy in the Name of* Insurance Company* Insurance Policy Number* Insurance ID Number* Health InformationAllergies/Dietary Restrictions* Current Medications* Any Additional Information You’d Like Us To Know* Parent/Guardian's InformationParent/Guardian Printed Name* First Last Parent/Guardian Signature* Date* MM slash DD slash YYYY Email* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Total NameThis field is for validation purposes and should be left unchanged.