OLPH HIGH SCHOOL RETREAT April 20th-21st

WHO? All high school students are welcome to attend. This form is due by April 1st. WHEN? The retreat starts at 9:00 a.m. on Saturday, April 20th, & will end after closing Mass at 3:30 Sunday the 21st. WHERE? The retreat will be held in Peninsula at CONSERVANCY for Cuyahoga Valley National Park at the White Pines Campus. See map & directions on back of this form. 3675 Oak Hill Rd. Peninsula, OH 44264 COST? The cost of the weekend is $45 per person. Make checks payable to Our Lady of Perpetual Help. WHAT TO BRING? Sleeping bag and or sheets and blanket, pillow, towel & toiletries, comfortable clothes/shoes WHAT NOT TO BRING? Do not bring any electronics! (Including cell phones, ipods, computers, etc Adults will have cell phones in case of emergency: Jeff Botos-216-973-6711 Julie Botos-440-552-9217
Please contact Jeff or Julie Botos with any questions

Please RETURN completed front & back with payment and parent signature by April 1, 2013 to the Parish Office. Dear Youth Minister: As the Parent/Guardian of _______________________________, a
(Students name)

participant in the OLPH retreat I hereby request permission for the above named child/children to attend the OLPH Teen Retreat and I consent to the childs participation in the retreat. I understand that I must provide transportation to and from the camp for my child. I hereby assume all risks in connection with the youth retreat and I further release discharge, and/or otherwise indemnity the Diocese of Youngstown, the Bishop of the Roman Catholic Diocese of Youngstown, Our Lady of Perpetual Help Parish, employees and volunteers from all claims, judgments, liability by or on behalf of my child, my self and my spouse for any injury or damage due to the childs participation in the youth retreat including all risks connected therewith whether foreseen or unforeseen. Furthermore, I acknowledge that it is my responsibility to provide adequate health insurance for my child/children. I understand I have the opportunity to call Julie Botos 440-552-9217 or Mary Houlahan 330-562-0725 about the youth retreat.
Signature of parent/guardian: ____________________________________ Teens Name _________________________________Age ___ Gr______ Address: _____________________________ City____________Zip_______ Parent(s)Name_______________________________________________ Parent cell phone________________Parents email_____________________ Teens Cell____________________ Home #:(____)________________ T-Shirt size_______ Food Allergies __________________ Vegetarian? _______________________

My teenagers photograph can be taken and used for different events and videos pertaining to OLPH Youth Ministry._____________________________________

Signature of parent

Please complete reverse

MEDICAL RELEASE (Please check and sign only those in accordance with your wishes.) In the event of an emergency, I hereby grant permission to transport my son/daughter and obtain emergency medical or surgical treatment from a licensed physician, hospital, or medical clinic. I hereby authorize medical personnel to release necessary information about my care to Julia Botos as parish group leaders(s) I wish to be advised prior to further treatment by the hospital or doctor. In the event I cannot be reached, please contact___________________________at_________________________. Relationship to youth _____________________________ Family physician __________________________. Phone _________________________.
(Please check one of the following)

My son/daughter is covered by hospitalization and medical insurance under policy #

_________________________________________ issued by _______________________________________. My son/daughter does not have medical coverage and I assume responsibility for the cost of hospitalization and medical care for my son/daughter. Signature: ________________________________________________ Date: ________ I hereby warrant that to the best of my knowledge, my son/daughter is in good health. I do not want any medical treatment to be given to my son/daughter under any circumstances. I hereby assume all responsibility for the health and well being of my son/daughter and release from responsibility the Bishop of the Diocese of Youngstown, and Our Lady of Perpetual Help parish, and the agents, associates, and employees of the Bishop and parish who have organized or participated in the supervision of such program. Signature: ________________________________________________ Date: ________ My son/daughter is taking medications at present. He/she will bring all such medications necessary and such medications will be well labeled. The names of, and concise directions for taking such medications, including dosage and frequency of dosage are as follows. ____________________________________________ Signature: _______________________________________________ Date: _________ No medication of any type whether prescription or nonprescription may be administered to my child unless the situation is life threatening and emergency treatment is required. Signature: _______________________________________________ Date: ________
___

I hereby grant permission for nonprescription medication (such as acetaminophen,

decongestant, cough syrup) to be given to my son/daughter, if requested by my son/daughter and deemed advisable by an adult chaperone. Signature: _______________________________________________ Date: _________

I wish to inform you of the following additional medical information and the
recommended course of action (allergies, dietary restrictions, special conditions, etc.)Signature: _______________________________________________ Date: ______