Youth 2 Youth Registration Retreat InformationDATE & TIME OF EVENT: Saturday: 10am-11pm at Assumption Sunday: 9:30am-1pm at Blessed Sacrament DESTINATION: Assumption Parish, Blessed Sacrament Parish DESIGNATED SUPERVISOR OF ACTIVITY: Justin Rose (989.941.8460) Kathy Russell (989.600.1112) CHAPERONES: Kim White, Julia Shields, Wendy Shields, Dave Pasek, Derrek Haddad, Renee Urlaub, Justin Rose, Kathy Russell METHOD OF TRANSPORTATION: Parent/Student DriverStudent Information & PermissionStudent Name First Last Student AgeGradePermission*I , the parent of the aforementioned student request that Blessed Sacrament Parish and Assumption of the Blessed Virgin Mary Parish allow my son/daughter, to participate in the activity described above. I give permission for my child to participate in said trip. In consideration for my son’s/daughter’s participation, I hereby release, save harmless and indemnify Blessed Sacrament Parish and Assumption of the Blessed Virgin Mary Parish, its employees, volunteers, agents and any sponsors or benefactors of said trip from any and all liability from any and all injury. I understand that my son/daughter will be under the supervision of the designated supervisor and chaperons on the stated dates and that all parish rules listed below will be in effect. I understand and agree that, if my son/daughter violates a parish rule, he/she will be sent home. I agree.Medical InformationMedical Consent*In case medical treatment is necessary and the parents or guardian cannot be located, the following authorization is needed, I (We) authorize the adult advisor in charge to consent to any neces¬sary examination, anesthetic, medical diagnosis, surgery or treatment, and/or hospital care to be rendered to the above named minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine in the state of Michigan. I agree..Allergies:Chronic diseases or medical problems:Medicines son/daughter is now taking:Medicines that need to be dispensed during this activity must be given to the designated supervisor in its original container with directions and dosage.Medical Insurance Carrier:*Policy/Contract Number:*Family Physician:*Physician Phone:*Parent (Gaurdian) Name:*Parent (Gaurdian) Signature*Contact InformationAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone:Work Phone:Cell Phone:Emergency Contact Name:*Emergency Contact Phone:*Family Email Parish Event Participant Agreement:Coupling swearing, smoking, drinking, gambling, possession of alcohol, drugs, or firearms are NOT permitted at our church youth functions. Any youth found in violation of these rules will have their parents called and will be sent home.Teen Signature*Date Date Format: MM slash DD slash YYYY Teen Cell Number (if applicable):CAPTCHACommentsThis field is for validation purposes and should be left unchanged.