Fidelis Fall Retreat

YOUTH Attending Fidelis Spring Retreat Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Address Please enter valid data.
City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.
Birth Date (mm/dd/yyyy) REQUIRED
Please type birth date in mm/dd/yyyy format
Please fill out this field. Please enter a date.
Current Grade REQUIRED Please fill out this field.

YOUTH'S PARENT Information

First Name Please enter valid data.

Last Name Please enter valid data.
Phone Number

Please enter a phone number.
Email Please enter an email address.

Dietary Needs

Dietary Needs
Explain below if there are dietary restrictions we need to know about
St. Elizabeth Ann Seton Catholic Church/Diocese Fort Wayne-South Bend Youth Ministry Event Parent/Guardian Participation Permission and Release
By typing my name below I acknowledge that as parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor ("participant").

In consideration of the aforementioned participant, my child, being allowed to participate in this event, I, on behalf of myself, my child and my child's other parent/guardian, hereby acknowledge recognition that such an activity may expose my child to risks and hazard not ordinarily encountered in the parish youth ministry program. Further, on behalf of myself, my chld and my child's other parent/guardian, I hereby release and agree to hold harmless the above named Parish and the Diocese of Fort Wayne-South Bend, inc. to the fullest extent permitted by law from any and all claims, judgments and liability of every kind for any injury and damage of any kind, whether personal or property, that we or any one of us may suffer or incur due to my child's participation in the event, regardless of whether the injury or damage is attributable to the fault of parties other than the Parish or Diocese or attributable to the fault, incliding negilgence, of the Parish or Diocese.

I have instructed my child to follow the rules of conduct as directed by the parish youth ministry program and Diocese.

Parent/Guardian Signature

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Date REQUIRED Please fill out this field. Please enter a date.

Emergency Contact Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Phone Number REQUIRED

Please fill out this field. Please enter a phone number.
Email REQUIRED Please fill out this field. Please enter an email address.

Consent to Emergency Medical Care

In the event of an emergency, I request that the parish make reasonable attempts to contact the emergency contact person listed above.

I understand that in an emergency, exigent circumstances may prevent the parish from contacting the above listed emergency contacts immediately, or the parish may be unable to reach them. I therefore consent to the parish taking action which it deems necessary to secure emergency medial care/treatment even if I have not been contacted.

I understand that decisions concerning the type of emergency medial care or treatment administered are normally made by health care providers and not by the parish and that exigent circumstances may require the administration of emergency medical care or treatment without my prior consent. However, I have indicated below any treatment preferences I have for my child which the parish may disclose to a health care provider. (Parents/Guardians may complete any of the following):
Preferred physician name and phone number Please enter valid data.
Preferred dentist name and phone number Please enter valid data.
I require the receipt of my consent prior to my child receiving major surgery unless the medical opinions of two licensed physicians or dentists, concurring in the necessity for such surgery, are obtained before surgery is performed. Yes No
Other medical or health/allergy related information you wish to provide.
Insurance Information:
Insurance Company Name Please enter valid data.
Policy/Group/Claim No.: Please enter valid data.
I understand that in the event of an emergency, the parish will make reasonable efforts to notify a health care provider of the above information, but i acknowledge that I am responsible for communicating such information to the appropriate medical personnel.
Parent/Guardian signature
By typing my name below, I certify that the above information is correct.
First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Date REQUIRED Please fill out this field. Please enter a date.

Additional Health Information

My child is taking and will be bringing with them the following medications. List names of medications, the dosage and frequency, and directions for each medication.
In the event that my child becomes ill with symptoms such as significant headache, vomiting, sore throat, fever, diarrhea, I want to be called. Yes No
Administration of Medication for headache, fever, sore throat, allergies, diarrhea, etc. 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. I hereby grant permission for non-prescription medication (i.e. non-aspirin products such as acetaminophen or ibuprofen, throat lozenges, cough syrup) to be given to my child if deemed appropriate
My child is allergic to (please list any foods, medications, insects, etc.) Please enter valid data.
Date of last Tetanus/diphtheria immunization: Please enter valid data.
My child was recently exposed to a contagious disease or condition (mumps, measles, chickenpox, etc.) If so, list the date and the disease or condition. Please enter valid data.
My Child has the following physical limitations: Please enter valid data.
Describe any medical conditions/emotional needs that you would like leadership to be made aware of. (i.e. diabetes, homesickness, sleepwalking, ADHD/ADD, Autism, bedwetting) All information will be held in confidence and shared only on an as needed basis.
By typing my name below, I certify that the above information is correct.
First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Date REQUIRED Please fill out this field. Please enter a date.

Fidelis Spring Retreat Fee

Select one (payment for this retreat is not required. You may make a donation if you would like) REQUIRED 0.0 – No fee 25.0 – Donation 50.0 – Donation 75.0 – Donation Please fill out this field.