Authorization for Student Excursion and Activities
For Co-Cathedral of St. Theresa Parish
The student's parent(s) or Legal Guardian (s) must complete the Authorization. If not completed and signed the student will not be allowed to participate in the activities and excursion described. Fax or phone permission IS NOT acceptable
Please print clearly.
Youth's Name:
Birth Date: - /- / 足 STREET
Sex:
OM
OF
ZIP
CITY
Parents' or Guardians' Name: - - - - - - - - - - - - - - - - - - - - - - - Home Phone: Work Phone: Cell Phone: - - - - - Phone: _
Name of Physician: Office Address: - - - - - - - - - - - - - - - - - - - - - - - - - - - Medical Insurance Plan: In case of an emergency, check one:
o Hospital preference:
Insurance No.: - - - - - - - - - _
o
No preference; closest hospital
Please list illnesses (example: asthma, heart condition, allergies, diabetes, etc.) that your child has and medications he/she is currently taking:
In case of an emergency and parent(s)/guardian cannot be reached, please call:
Emergency contact:
Phone:
_
I/We, the parent(s)/legal guardian, give my/our permission for the above named youth to participate in the:
Event: St. Theresa Life Teen Confirmation Retreat Date: Friday, May 7 - Sunday, May 9, 2010 Place: St. Stephen's Diocesan Center I amlwe are the parent(s)/guardian(s) of the above named student. By signing below, IIWE: a. b. c.
d.
Give permission for the above named student to participate in the excursion and activity named above. Give permission for the student named above to travel by private or commercial vehicle. Release St. Stephen's Diocesan Center and Co-Cathedral ofSt. Theresa parish and its agents and employees from any and all liability to the student for any injury, damage, or loss that occurs because of the stuQent's participation in the excursion and activity, unless the injury, damage or loss is caused by gross negligence or willful misconduct of the Parish or its agents and employees; and; In the event of illness or injury to the student, consent to and authorize such medical and dental treatment as may be deemed necessary, and agree to pay for such medical and dental treatment costs.
Parent(s)/Guardian(s) Signature:
Date:
_
YOUTH AGREEMENT:
I accept and comply with all the rules and regulations set down at the event location and by the event organizers. I will honor and respect the people and property associated with this event.
Youth Participant's Signature:
Date: - - - - - -
Retreat Expectations
1) Actively participate in all activities, including active listening 2) Respect leaders, chaperones, and each other 3) Wear your name tag at all times 4) Bring your retreat packet at all sessions 5) Keep an open mind and be flexible 6) Leave personal conflicts "at-the-door" 7) Communicate your feelings 8) Collaborate well in groups 9) Follow ground rules 10) Be prompt 11) No teasing 12) Be responsible 13) Go to your own rooms when "Lights-Out" is called 14) No wandering around outside once "Lights-Out" is called 15) No swearing 16) No use of ANY electronic devices (cell phones, mp3 players, etc.) during the retreat. 17) Confidentiality is vital. Whatever is said at retreat stays in retreat. Zero Tolerance Issues
1) 2) 3) 4) 5)
Harassment - physical, sexual, emotional, or mental Insubordination Alcohol/tobacco/drug use Cohabitating in rooms Defacing/breaking of physical property
I have read the above and agree to the rules and regulations as well as the zero tolerance issues. I realize that if the zero tolerance rules issues are violated, then I can be sent home at my parents' expense. If I am conducting myselfwith criminal knowledge or intent, I agree to be prosecuted to the full extent ofthe law.
(Print your name)
(Sign your name)
(Date)
** PLEASE BRING THE FOLLOWING ITEMS: • Bedding: Bedding & towels will be provided by the retreat center. You may bring extra blankets/pillows/towels if you prefer. • Toiletries: Towels, soap, toothbrush, toothpaste, deodorant, etc. • Clothing: Comfortable clothes and enough clothes for the entire retreat. Evenings will be cool, so don t forget to bring a warm jacket/sweater. I
• Appropriate shoes: Walking, running, or tennis shoes and/or slippers • Miscellaneous: Bug spray, mosquito repellant, flashlight, etc.
* Dress appropriately.
No baggy clothes, low-midriffs, low-cut tops, etc. *
* Be reminded that this is a
church function and we are to represent St. Theresa
respectfully as possible *
*** The following Hems are
not allowed on retreat. They will be confiscated and returned at the end of camp. Co-Cathedral of st. Theresa and its agents and employees are not responsible for any lost or damaged items:
Cell phones, CD/DVD players, radios, MP3 players, and Video games
IMPORTANT INFORMATION AND PHONE NUMBERS Fay Castillo
Mobile: (808) 330-8977
Youth Minister - Co-Cathedral st. Theresa Fr. William Kunisch
Phone: (808) 521-1700
Rector - Co-Cathedral of St. Theresa st. Stephen's Diocesan Center
6301 Pali Highway Kaneohe, Hawaii 96744
Phone: (808) 263-8844 ext. 324