T H E	R E Z
REGISTRATION & MEDICAL RELEASE FORM

Participant’s Name								Parish/School

Name of Event:	The Resurrection Retreat “The Rez!” Location:	Triple-R Ranch, Chesapeake, VA
Sex	Date of Birth	 
Home Address  							  City				State		Zip  		  Home Phone (		)		Work (	) 			 Cell phone (	) 		
NAME OF PARENT/GUARDIAN: 	
Insurance Company:  		 Policy Holder’s Name:  		  Relationship to Policy Holder:  	  Policy Number:  	
In case of an emergency notify:  				  Home No. (	)	Work No. (	) 	 Cell phone (	) 		

Medical Information
1)	Does your child have any allergies?	YES	NO If “YES”, please list

2)	Does your child have medication of any type, with them? If “YES”, please list.

3)	Is there any other physical or emotional condition of which we need to be aware? Please explain.

In the event of any emergency, I give authority to the accompanying adults to authorize treatment. I understand that an attempt to notify me will be made before any treatment is authorized.

PARENT /GUARDIAN SIGNATURE:

 	Date  	

PARENT/GUARDIAN CONSENT FORM AND
LIABILITY WAIVER

Participant’s Name								Parish/School

Parent(s)/Guardian(s)

I/We, [Parent/Guardian named above] grant permission for my child [Participant named above] to participate in this event. I understand that this event will take place under the guidance and direction of the Missioners of Christ, a Catholic Non-profit organization. My understanding of the event is:

Event: The Resurrection Retreat “The Rez!”

Place/Destination: Triple-R Ranch, Chesapeake, VA

Individual(s) in Charge: Sarah Hartung (facilitator) and your youth minister

Date(s) and Time(s): November 18-20, 2016

Mode of Transportation:  	

Please describe below any special instructions, arrangements, directives or precautions that need to be followed with your child.

As parent/legal guardian, I remain legally responsible for any personal action taken by my child. I agree to hold harmless this parish/school [named above], Missioners of Christ, Triple-R Ranch, and the Diocese of Richmond as well as its officers, directors, agents, chaperons, or representatives associated with this event, arising from or in connection with my child attending this event, or including but not limited to accidents, emergencies, exposure to reckless conduct of persons.

PARENT/GUARDIAN SIGNATURE:

 	Date  	

The Rez Retreat is facilitated by the Missioners of Christ, a Catholic Nonprofit Community & Apostolate  www.missioners.org † info@missioners.org † (757) 424-8774 / (703) 831-0684 [FAX]

Rez Retreat – Payment Form

Student Name:

After a parish subsidy, the cost of the retreat is $100. Payment can be in the form of cash or check made out to “Our Lady of Lourdes.” The forms and payment can be returned in person or via mail to the church, but please make sure to mark them “Attn: Youth Ministry”

Please select from the following options:

_____ I am paying the $100 registration fee and have included it with this form.

_____ In addition to the registration fee, I would like to make an additional donation to the OLL Youth Ministry Travel and Scholarship fund in the amount of $_____ and have included it with this form.

_____ I am requesting a scholarship for this event. I am requesting an additional $_____in support and have included the remaining $_____ with this form.