Our Lady of Mount Carmel Confirmation Retreat

Transcription

1 (361) Fax (361) Our Lady of Mount Carmel Confirmation Retreat April 14th, 2019 Open to 2 nd Year Confirmation Candidates & their Sponsor Held at: Fannie Bluntzer Nason Renewal Center: dba The Spirit Center Bluntzer, Texas Retreat is from 10:00 am 4:00 pm: Concludes back at OLMC 5:30 mass ************************************************************************************************** Teen s Name Age Grade Teen s Address City State Zip Teen Cell Phone # Parent/Guardian s Name Address / / Parent/Guardian s: Home Phone # Work Phone # Cell Phone# Parent Address Sponsor s Name ****************************************************************************************************************************************** Each Candidate s & Sponsor s cost is $30.00 each, which includes a lunch, snacks and retreat expenses. Total Fees Submitted in this Packet Please return forms with a single check payable to OLMC or Our Lady of Mt. Carmel Registration Deadline is Sunday, March 24 th, 2019 Forms can be turned in at TGIF nights to an Adult Leader or the Religious Ed Office. Sponsors are required to attend the retreat with the Confirmation Candidate. If a Sponsor can t attend, adult proxy is required to fill in. Coordinator: Kyle Nohavitza

2 Page 1 of 2 (Youth Consent) Diocese of Corpus Christi/ Office of Youth Ministry Parish: Our Lady of Mount Carmel, Portland, TX Confirmation Retreat PARENTAL/GUARDIAN CONSENT, LIABILITY WAIVER AND MEDICAL CONSENT Participant s Name of Birth Home Address City Zip Code Parent(s)/Guardian(s) Home Phone ( ) Alternate Phone Number: ( ) Cell Phone Parish or Catholic School Grade Age Sex PARTICIPATION CONSENT, LIABILITY WAIVER & PHOTOGRAPHY/VIDEOGRAPHY CONSENT Important! To be filled out by the Parent/Guardian for youth under 18 years of age. (If participant is 18 years of age or older, consent must be signed by the individual) I (name of parent/guardian), grant permission for my child, (participant s name), to participate in the OLMC Confirmation Retreat to be held on April 14th, 2019 at The Spirit Center: Bluntzer, Texas. I agree on behalf of myself, my child s other parent if known or living (name of parent), my child named herein, or our heirs, successors, and assigns, to release and hold harmless and defend the Diocese of Corpus Christi, the sponsoring parish (its pastor, youth minister, principal, other agents, etc.) or any representatives associated with the scheduled activity from all damages, claims, suits, expenses and payments for injury to my child and/or property, including all damages, claims, suits, expenses and payments resulting from the negligence of the Diocese of Corpus Christi, and parish, and/or their officers, directors, and employees. As parent/guardian, I understand that promotional pictures (individual and group) will be taken during this event. I give permission for my son s/daughter s picture to be used for promotional materials (newsletter, web page, calendars, power point, video, etc.) in highlighting the event. Signature (Parent/Guardian) Signature (Participant 18 years of age or older must sign own consent)

3 Medical Consent Page 2 of 2 (Youth Consent) Medical Matters I hereby warrant to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. Of the following statements pertaining to medical matters, sign only those in accordance with your wishes: Emergency Medical Treatment In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency and you are unable to reach me, contact: Name & Relationship Phone Family Doctor Phone Medications: My child will bring all such medications, well labeled, that are necessary. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency are as follows: Medication(s): Dosage: Administer: I hereby Do Not Grant Permission for medication of any type, whether prescription or nonprescription may be administered by my child unless the situation is life threatening and emergency treatment is required. (Please initial) I hereby Grant Permission for nonprescription medication (such as Tylenol, throat lozenges, cough syrup) to be given to my child, if deemed advisable. I understand that Aspirin will not be given to my son/daughter. (Please initial) Medical Conditions Information (Diocesan personnel will take reasonable care to see that the following information will be held in confidence.) Allergic reactions to the following (foods, dyes, latex etc.) Has had a medical surgery within the last six months? Yes / No Still under doctor s care? Yes / No Has a medically prescribed diet? The following physical limitations? Immunizations current and up to date: Yes / No of last tetanus/diphtheria immunization You should also be aware of these special medical conditions of my child: Insurance Information (Please attach a copy of the Insurance Card, front and back, with this form) Insurance Carrier: Name of Insured: Insurance Policy Number: Father s Name: Mother s Name Day Phone: Day Phone: No, I do not carry medical insurance at this time. In the event it comes to the attention of the chaperones associated with the activity that my child becomes ill with repeated symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called immediately. If this will be a long distance call, I want to be called collect (with phone charges reversed to myself). I fully understand the foregoing statements and sign this Parental/Guardian Medical Consent Waiver knowingly, freely, and willingly. Signature (Parent/Guardian) Signature (Participant 18 years of age or older must sign own consent)

4 Diocese of Corpus Christi and/or Parish of Adult Participant s (Sponsor) Release of Liability and Medical Release Form Name: Parish: Daytime Phone # Address: City: State: Zip: Health Insurance Carrier: Insurance ID Number: Insurance Policy Number: Name of Event: OLMC TGIF Confirmation Retreat of Event: April 14th, 2019 Location of Event: Fannie Bluntzer Nason Renewal Center: dba The Spirit Center : Bluntzer, Texas. I agree on behalf of myself, my heirs, successors, executors, personal representatives and assign to protect, indemnify, save, and hold harmless the Diocese of Corpus Christi, and _Our Lady of Mt. Carmel Catholic parish, and their officers, directors, agents employee, or representatives associated with this event/trip from all damages, claims, suits, expenses and payment on account of or resulting from conditions stated on or resulting from any such injury, death, or damage to property, including resulting from the negligence of the Diocese of Corpus Christi, and parish, and/or their officers, directors, and employees arising from or in connection with my attending youth ministry events. In the event that any legal action is taken by either party against the other party to enforce any of the terms and conditions of this agreement, it is agreed that the unsuccessful party to such action shall pay to the prevailing party therein all court costs, reasonable attorneys fees and expenses incurred by the prevailing party. In the event that I should require medical treatment and am not able to communicate my desires to attending physicians or other medical personnel, I give permission for the necessary emergency treatment to be administered. Please advise the doctors that I have the following allergies: (Signature) () In case of an emergency and for permission for treatment beyond emergency procedures, please contact: Emergency Contact Name: Relationship to me: Day Time Phone #: Night Time Phone #:

5 Fannie Bluntzer Nason Renewal Center: dba The Spirit Center, in Bluntzer, TX Fannie Blunter Nason Renewal Center, also known as The Spirit Center, is a Catholic retreat facility embracing people of other faiths. The Spirit Center offers meeting space, overnight accommodations and dining facilities to groups within an environment of natural beauty and peace, for the spiritual, educational, and social development of youth. Space is provided for outdoor activities and games. Directions to the Spirit Center: The Spirit Center is about 25 miles from Corpus Christi, 10 miles from Calallen, 10 miles from Orange Grove, 15 miles from Mathis, 6 miles from Banquete, about 15 miles from Robstown. From FM 624 west, turn right, north, toward Mathis on FM 666, at the corner of the old Bluntzer School (Fourway stop, blinking light) Travel approximately one/third mile and turn left on FM 3088(can only turn left). Pass the historical marker on the right, watch for first drive after the marker, and turn right at the Spirit Center entrance. Proceed straight along the drive, pass the Bluntzer home on the right, and then follow the road through the gate to the left. You will see the Center on the left.