to download and print a retreat application (PDF) - ACTS-Holy Rosary

HOLY ROSARY TEEN ACTS RETREAT
APPLICATION
Participant’s Name: ________________________ Age: _______ (on June 9) Birthdate: _____________
Sex: _____ Cell:_________________________ School: _________________ Graduation year:________
Student Email: ____________________________ Parish: _________________________________________
Address: _________________________________ City:____________________ Zip:____________
Parent/Guardian Name: _____________________________________________________________________
Home phone: _____________________________ Cell: ___________________ Work: _________________
Address (if different from participant):_______________________________________ City:__________________
Parent email:_______________________________ T-SHIRT SIZE______________________
ATTENTION
PLEASE MAIL COMPLETED PARENT/GUARDIAN CONSENT FORM AND MEDICAL
CONSENT FORM ALONG WITH A $20.00 REGISTRATION FEE TO:
TEEN ACTS
SANDRA MURAS
1107 Lyons Ave
Schulenburg, Tx 78956
NO HAND-DELIVERED FORMS WILL BE ACCEPTED.
THE FORMS MAY NOT BE POSTMARKED BEFORE APRIL 4,2011.
THE $20.OO FEE IS PART OF THE ENTIRE FEE OF $50.00*. THE REMAINDER OF THE FEE IS
DUE ON OR BEFORE THURSDAY,JUNE 9 DURING REGISTRATION.
IF YOU ARE NOT ACCEPTED OR HAVE TO CANCEL, THE INITIAL DEPOSIT FEE WILL BE RETURNED TO YOU.
*If you want to attend and are not able to pay the fee, scholarships are available.

PARENTAL/GUARDIAN CONSENT FORM & LIABILITY WAVER
I, _________________________(printed name of guardian) grant permission for ___________________to
participate in this youth ministry event that requires transportation to a location away from the parish site.
This activity will take place under the guidance and direction of employees and/or volunteers from Holy
Rosary, Hostyn and surrounding parishes. A brief description of the activity follows:
Type of event: Teen ACTS Retreat
Date of event: June 9-12
Cost: $50 per participant, $30 for next family member
Destination: Cathedral Oaks
Individual in charge: Sandra Muras
Estimated time of departure: June 9 at 6:30
Estimated time of return: June 12 at 10:00 Mass in Hostyn
Mode of transportation: Bus from Hostyn
Activities: Interaction with youth and adults concerning
religious, spiritual, moral and social issues;
prayer and scripture sharing, physical games
and exercises, and water activities
As the parent/guardian, I remain legally responsible for any personal actions taken the above named
minor (“participant”).
I agree on behalf of myself, my child named herein, our heirs, and successors to hold harmless and
defend the parish of Holy Rosary, Hostyn, their officers, directors and agents: the Diocese of Victoria, or
representatives associated with the event for reasonable attorney’s fees and expenses arising in
connection therewith.
______________________________________________
Please print name
_______________________________________________ ________________
Signature of Parent/Guardian Date
_________________________________
Number to call in case of emergency
To the best of my knowledge, my child, _________________________________, is in good health,
and I assume all responsibility for the health of my child.

MEDICAL CONSENT AND PERMISSION TO TREAT
Emergency Medical Treatment: In the event of an emergency, I hereby grant permission to
transport my child to a hospital for emergency medical treatment. YES _______ NO _______
Parent/Guardian: __________________________________________________________
Address:____________________________________________________________________
Home phone: ____________ Cell:_______________ Work phone: ______________
If you are unable to reach me, contact:
Name: __________________________________________________________________________
Relationship to me or my child:_______________________________________
Home phone: ______________ Cell:____________Work phone: _________________
Family Doctor: _________________________Phone # __________________________
Please include a photocopy of your insurance card (front and back).
Insurance carrier: ________________________ policy # ________________
My child is taking medication and will bring it with him/her. It will be clearly labeled. My child is
taking the following medication(s) and directions for taking this medication, including dosage,
frequency and storage are as follows:
________________________________________________________________________
I hereby grant permission for non-prescription medication (such as cough drops,cough syrup,
Tylenol, etc.) to be given to my child if necessary: YES ____NO ____
I understand that aspirin will not be given without my express permission. I hereby grant such
permission. YES______ NO _______
My child is allergic to the following:________________________________
My child’s immunizations are current and up-to-date: YES____ NO ______
My child has the following physical limitations: _____________________________________
My child experiences homesickness, emotional reactions to new situations, sleepwalking,
fainting, etc. YES ________ NO _________
My child has recently been exposed to a contagious disease such as mumps, measles,
chicken pox, etc. YES ______ NO_________ If yes, explain:________________________
My child is suffering from a psychological condition which my affect of limit his/her ability to
participate in this activity. YES____ NO ______
__________________________________________________ _____________________________
Signature of parent/guardian Date