Life Teen Walk for Life

 

Participant Information

Teen's Name*
Gender*
Date of Birth*
Address*
Grade*
How did you hear about this retreat?*
This is my teen's first time attending a Life Teen Retreat at St. Timothy:*
T-Shirt Size (adult sizes only)*
Up to two people may be requested
My son/daughter has my permission to receive basic over the counter medication if necessary.*
Add a second teen?*

Participant 2 Information

Teen's Name*
Gender*
Date of Birth*
Address*
Grade*
How did you hear about this retreat?*
This is my teen's first time attending a Life Teen Retreat at St. Timothy:*
T-Shirt Size (adult sizes only)*
Up to two people may be requested
My son/daughter has my permission to receive basic over the counter medication if necessary.*
Add a third teen?*

Participant 3 Information

Teen's Name*
Gender*
Date of Birth*
Address*
Grade*
How did you hear about this retreat?*
This is my teen's first time attending a Life Teen Retreat at St. Timothy:*
T-Shirt Size (adult sizes only)*
Up to two people may be requested
My son/daughter has my permission to receive basic over the counter medication if necessary.*

Parent Information

Parent (Guardian) #1 Name*
If my email is not on the parish mailing list, please add:*
Parent (Guardian) #2 Name
If my email is not on the parish mailing list, please add:
Emergency Contact (Other than listed above)*

Waiver

I request that the St. Timothy Life Teen program allow my child(ren) named above to attend the Life Teen Walk for Life, January 22-26, 2020, in San Francisco, California. In consideration for my child(ren)'s participation, on behalf of myself, my child(ren), and our heirs, assigns, executors and personal representatives, I hereby release, absolve, indemnify and agree to hold harmless St. Timothy Roman Catholic Parish in Mesa, the Roman Catholic Church of the Diocese of Phoenix, and any and all of their officers, directors, agents, employees, representatives, volunteers, or sponsors from any and all liability for any and all injury that may arise out of participation in this activity. I authorize the supervisor of the retreat or his/her designee to provide first aid or similar care in non-emergency situations and to seek emergency medical assistance when they deem it necessary, for which I will be financially responsible. I also agree to release, absolve and hold harmless St. Timothy Catholic Church for any and all damage sustained to my vehicle should I choose to leave it in the parking lot while attending this event. Further, I give permission to have photographs taken of me for the purpose of parish use. Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action or otherwise (as determined by youth minister), I understand that I am responsible for picking up my youth or arranging for transportation in a timely manner, and assuming all transportation costs and responsibility. I understand that as a preventive measure and in order to maintain a safe environment, random searches of youths’ personal possessions may be made. I agree that my youth’s personal possessions may be searched when or if a youth minister has reasonable suspicion that a youth may possess an item in violation of event rules.

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Date/Time*

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