High School Winter Retreat 2024 – Permission Form – St. Leo the Great Catholic Church

1Information

2Parental Permissions

3Health Information

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Participant's Name *

Address

Address Line 1

City

State

Zip Code

Home Phone Number *

Parent's Name *

Parent Phone Number *

Parent Email Address *

Safety: As the participant, I agree to follow all procedures, safety precautions, and rules and regulations set forth by the Diocese and the Parish.

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Signature of (Youth) Participant *

Date *

Parental Permission and Liability Release:

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As parent or legal guardian of the participant names above, I give my permission to participate fully in Winter Retreat at Hunting Ridge (1011 Hunting Ridge Road Winchester, VA 22603) from February 9 at 4:15pm to February 11 at 3:30pm. I agree to indemnify and hereby release the Most Reverend Michael F. Burbidge of the Catholic Diocese of Arlington and his successors in office, as well as the Catholic Diocese of Arlington and all Diocesan clergy, employees, volunteers, and participating parishes and schools from any and all liability, claims, and demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned of the participant resulting from said participant’s involvement in the above-mentioned event (including transportation to and from the event). Furthermore, I, on behalf of the participant, hereby assume all risk of personal injury, sickness, death, damage, and expenses resulting from said participant’s involvement in the above-described event.

Name of Program or Trip *

Start Date/Time *

Date

Time

End Date/Time *

Date

Time

Informed Consent to Medical Treatment:

I request that, in my absence, the above-named minor be admitted to any hospital or medical facility for diagnosis and treatment when a condition or injury arises that is serious enough that a reasonable person would seek care right away. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures, and x-ray treatment of the above minor. I have not been given a guarantee as to the results of the examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor. I assume full responsibility for all costs of such treatment. Further, should it be necessary for the participant to return home due to medical, disciplinary, or other reasons, I do hereby assume responsibility for the participant’s transportation home and any costs related thereto.

Photo, Press, Audio, and Electronic Media Release:

I authorize the Catholic Diocese of Arlington, its parishes, its schools, and/or the Arlington Catholic Herald to use and publish my child’s photograph, video, and/or audio recording along with their name, identifying them for educational, news stories, illustration, and/or marketing purposes.