NET RETREAT
REGISTRATION
PARENTAL/GUARDIAN CONSENT FORM
LIABILITY WAIVER  

Submit by January 30th to your parish Director of Religious Education, the front office at Parkersburg Catholic High School, or mail to:  

Catherine Wharton
St. Margaret Mary Parish
2500 Dudley Avenue
Parkersburg, WV  26101

I’m registering for the following retreat:
         __ Grade 6-8 Retreat at St. Ambrose Catholic Church (February 6^th, 9 – 4pm)
         __   Grade 9-12 Retreat at St. Margaret Mary PAC (February 9^th, 8am – 5pm)
          __  Confirmation Retreat at St. Monica Catholic Church (February 7^th, 10:30am – 5pm)
           __ Parkersburg Catholic High School Retreat at St. Francis Xavier Center (February 8^th, 8 – 3pm)

Participant’s Name:  ____________________________________________________________

Birth Date: ____________________ Gender: _______________Grade: _______________

Parent/Guardian’s Name_________________________________________________________

Home Address: ________________________________________________________________

Home Phone: ______________________________Cell Phone: __________________________

 I, ______________________________, grant permission for my child, ____________________
            Parent or Guardian’s Name                                                                  Child’s Name
to participate in this youth event.

Type of Event: N.E.T. Retreat

As parent/and or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (participant).  

I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend the parish at which the event is held, its officers, directors and agents, the diocese to which that parish belongs, Parkersburg Catholic High School, and chaperones, or representatives associated with the event, arising from or in connection with my child attending the event or in connection with any illnesses or injury or cost of medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors and agents, the diocese, Parkersburg Catholic High School, chaperones, or representatives associated with the event for reasonable attorney’s fees and expenses arising in  connection therewith.

 Signature: _________________________________________        Date: __________________

 
Medical Matters:  I hereby warrant that 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 that are applicable.)

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, if you are unable to reach me at the above numbers, contact:

Name and Relationship:  ______________________________________ Phone: _____________________

Family Doctor: ______________________________________________ Phone: _____________________

Family Health Plan Carrier: ____________________________________ Policy #_____________________

Signature:___________________________________________________ Date: _____________________

 Other Medical Treatment: In the event it comes to the attention of the parish, its officers, directors and agents, the diocese, Parkersburg Catholic High School, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reversed to myself).

Signature: _______________________________________________         Date:  ___________________

No medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life threatening and emergency treatment is required.

Signature: _______________________________________________         Date:  ___________________

I hereby grant permission to non-prescription medications such as (aspirin, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.

Signature: _______________________________________________         Date:  ___________________

Specific Medical Information: The parishes will take reasonable care to see that the following information be held in confidence.

Allergic reactions (medications, foods, plants, insects, etc.): ____________________________________

Immunizations: Date of last tetanus/diphtheria immunization: ___________________________________

Does child need special accommodations (please specify)?  ____________________________________
_____________________________________________________________________________________

Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc.? If so, date, disease or condition: ____________________________________________

You should be aware of these special medical conditions of my child:

________________________________________________________________________________________________________________________________________________________________________