Proclaim Your Flame Retreat (Hosted by G.L.O.W.) PERMISSION & AUTHORIZATION FORM Child's Name* First Last Event: PROCLAIM YOUR FLAME RETREAT (Hosted by G.L.O.W.) When: 3:00 PM – 10:30 PM Saturday, February 22, 2020 Place: Holy Family Catholic Community 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 necessary.Home Phone Number*Other number (if applicable)Teen’s Year of Graduation (select one)* 2020 2021 2022 2023 Teen E-Mail* Teen Cell Phone*Address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent's Name(s)* Mother E-mail:* Mother Cell #:*Father E-mail:* Father Cell #:Family Physician* Phone Number*Name of Insurance Co.* Policy Number* Person to contact in case of emergency (if unable to reach parent): Name/Relationship* Phone Number*Parent(s) Name(s)* Specific medical allergies, food allergies, chronic illnesses and other conditions. Please list any & all medications that your child may take during the retreat.*Authorizations* I understand that the $10 cost of this retreat is due at the time of registration or my son/daughter’s spot will not be held. I understand and agree to pay the full cost of this retreat ($10) by February 20, 2020. Cancellations after February 16, 2020 will be responsible for entire retreat cost. I understand that my retreat payments are nonrefundable and nontransferable to other retreats or events. I understand that by signing my teen up for this retreat, he/she will attend the retreat in its entirety, from 3 PM until 10:30 PM. In the event of an extenuating circumstance, a parent must contact Grant Guthrie at email@example.com or (847) 907-3439 to arrange for alternative plans. Parent/Guardian Signature* Date* MM slash DD slash YYYY :I have read and understand the rules and agree to comply with them.Teen Signature* Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.