Ignite Retreat Permission Form

Name*
Age*
Will Your Child Stay the Night?*
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
Teen Cell Phone*
Teen Email*
Parent's Name(s)*
Parent E-mail*
Parent Cell #*
Parent Cell*
PERMISSION & AUTHORIZATION FORM FOR MEDICAL TREATMENT

I/We, the parent(s) of the above teenrequest that Holy Family Teen Faith program allow my/our child to participate in

Event: Ignite Lock-in/Retreat When: February 1-2, 2020 with check-in at 3:45pm at Holy Family Place: Holy Family Parish

I hereby release and indemnify Holy Family Parish, its staff and its volunteers and the Catholic Bishop of Chicago, a corporation sole, from any and all liability arising from claims of any kind or nature whatsoever from my child’s participation in this event.

In the event that the undersigned or my (our) authorized physician, cannot be reached, and in the judgment of a responsible person accompanying the group, or other appropriate staff member, there is a necessity for immediate examination and/or treatment of my (our) child, I/We hereby authorize any of the aforesaid people to obtain for my child such medical services as are deemed
Family Physician*
Phone Number*
Name of Insurance Co.*
Policy Number*
Emergency Contact Name and Phone Number, if different than parent’s numbers:
Name/Relationship*
Phone Number*
Parent(s) Name(s)*
Specific medical allergies, chronic illnesses and other conditions. Please list any & all medications that your child may take during the retreat.*
Media/Photo Waiver
- Y
- N
I herby authorize and give my full consent to Holy Family Community to publish any and all photographs, video or audio in which I/my child will appear in while attending this event. I further agree that Holy Family Catholic Community may transfer these photographs, video or audio for use on the Holy Family website, social media and promotional
Electronic Parent/Guardian Signature*
Date*
MM slash DD slash YYYY
Teen Signature*
Phone
This field is for validation purposes and should be left unchanged.