Youth 2 Youth Registration

Retreat Information
DATE & TIME OF EVENT: Saturday, April 22, 2023: 9:00am - Sunday, April 23, 2023: 4:00pm at Camp Rotary

DESTINATION: Camp Rotary; 3201 S. Clare Ave; Clare, MI Phone: 989-386-7943

DESIGNATED SUPERVISOR OF ACTIVITY: Justin Rose (989.941.8460) Kathy Russell (989.600.1112) Camp Rotary (989.386.7943)

CHAPERONES: Dave Pasek, Wendy Shields, Kim White, Renee Urlaub, Derek Haddad, Justin Rose, Kathy Russell, Kristyn Russell, Justin Dean, Callie Losinski

METHOD OF TRANSPORTATION: Carpool

DRIVERS NEEDED
(Please note: The minimum acceptable liability limits for a privately owned vehicle is $500,000 CSL [Combined Single Limit] or an Umbrella Policy. Drivers must fill out a Volunteer Driver Information Sheet located in the Faith Formation Office and have both sides of your drivers license copied.)

Adult Chaperones: If you can spare some time to help keep our kids safe during our time together, please mark "yes" on this form or call Justin Rose.

COST: $65.00
Student Information & Permission
Student Name
First Last
Student Age
Grade
Permission*
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 Information
Medical 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 Information
Address*
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
MM slash DD slash YYYY
Teen Cell Number (if applicable):

Carpool Driver
Are you interested in driving to or from the retreat?
- No
- Yes
Name
First Last
Email
Phone
Have you attended VIRTUS?
- Yes
- No
I can help with...
- Driving only TO
- Driving only BACK
- Driving both TO & BACK
How many YOUTH can you take (also taking into account luggage)?
Year/Make
License Plate #
Expires
Insurance Company
Policy #
Expires
I certify that the information given on this form is true and correct to the best of my knowledge. I certify that as a volunteer driver, I hold a valid driver’s license and have the required insurance coverage in effect on this vehicle. The undersigned driver agrees to indemnify, hold harmless and defend the Midland Area Catholic Churches together with their employees, agents and representatives from any and all claims for damage to a person or property caused in part or wholly by the undersigned.

Please note: The minimum acceptable liability limits for a privately owned vehicle is $500,000 CSL [Combined Single Limit] or an Umbrella Policy. Drivers must fill out a Volunteer Driver Information Sheet located in the Faith Formation Office and have both sides of your drivers license copied.
Signature
Date
MM slash DD slash YYYY

Step 1 of 6

Retreat Information

Student Information & Permission

Medical Information

Contact Information

Parish Event Participant Agreement:

Carpool Driver

Chaperones