ROCK 2019-2020 Retreat Registration

Registration due no later than Monday, June 24th.
Participants

Participant Name Participant Name First Last
School Attending
Grade: (current 2018-2019 school year)

Grade: (current 2018-2019 school year) 4th 5th 6th 7th
Is participant advancing to the next grade for the 2019-2020 school year?

Is participant advancing to the next grade for the 2019-2020 school year? Yes No
Birthdate Birthdate / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Parent/Guardian Name
Parent/Guardian phone: Parent/Guardian phone: - ### - ### ####
Parent/Guardian Email
Terms:

I understand that registering for the St. Peter ROCK Retreat commits me/my child to act in an appropriate Christian manner toward both my peers and adults, and to obey the St. Peter Youth Ministry Rules as stated by the St. Peter Youth Minister and Pastor. By signing here, I understand and agree to the above terms.
Parent's Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Participant's Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Medical Information and Consent Form

St. Peter Jr. High Youth Ministry
Must be filled out to participate in any ROCK event
GENERAL INSTRUCTIONS TO PARENTS/GUARDIANS/ADULTS:

Please take care in filling out this form. It provides crucial information for caregivers in the event of illness or medical emergency. Accuracy and thoroughness are encouraged.
ROCK Member's Name ROCK Member's Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Gender

Gender Male Female
Parent/Guardian's Name: Parent/Guardian's Name: First Last
Parent/Guardian's Email
Parent/Guardian's Phone number: Parent/Guardian's Phone number: - ### - ### ####
Parent/Guardian's Phone secondary number: Parent/Guardian's Phone secondary number: - ### - ### ####
Emergency Contact Name
Emergency Contact Phone Emergency Contact Phone - ### - ### ####
SECTION I -- MEDICAL MATTERS -- MANDATORY

As the Parent/Legal Guardian said above, who is currently associated with St. Peter Youth Ministry, I hereby authorize The Youth Ministers and/ or his/her assistants to carry out the wishes I have named (herein) in areas of emergency medical treatment and other cases of illness. This authorization inclusively extends from September 1, 2018, through August 31, 2019. I hereby warrant that, to the best of my knowledge, said person is in good health, and I assume all responsibility for the health of said person.
Parent/Guardian's Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY
SECTION II - EMERGENCY MEDICAL TREATMENT -- MANDATORY

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 numbers listed herein, contact:
Name: Name: First Last
Relationship to Child:
Phone Phone - ### - ### ####
Family Doctor Name:
Doctor's Phone: Doctor's Phone: - ### - ### ####
Family Health Plan Carrier:
Policy #:
Parent/Guardian's Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY
SECTION III - OTHER MEDICAL TREATMENT

In the event it comes to the attention of the parish, its officers, directors and agents, and the Archdiocese of New Orleans, chaperones, or representatives associated with the activity that said person becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reversed to myself).
Parent/Guardian's Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY
SECTION IV - MEDICATIONS

SIGN ONLY THOSE OPTIONS THAT ARE APPLICABLE
Said person is taking medication at present. Said person will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for seeing that the said person takes such medications, including dosage and frequency of dosage, are as follows:
Parent/Guardian's Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY
I hereby grant permission for non-prescription medication (such as aspirin, throat lozenges, cough syrup) to be given to said person, if deemed appropriate.
Parent/Guardian's Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY
NO medication of any type, whether prescription or non-prescription, may be administered to said person unless the situation is life-threatening and emergency treatment is required.
Parent/Guardian's Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY
SECTION V -- MEDICAL INFORMATION

The parish will take reasonable care to see that the following information will be held in confidence.
Allergic reactions (medications, foods, plants, insects, etc.):
Immunizations:
Date of last DTaP: Immunizations:
Date of last DTaP: / MM / DD YYYY
Date of last MMR Date of last MMR / MM / DD YYYY
Immunization Notes:
Has said person recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc?
If yes, date and disease or condition:
Does said person have a medically prescribed diet?
Any physical limitations?
You should be aware of these special medical conditions of said person:
St. Peter Parish Catholic Church
125 E. 19th Avenue
Covington, LA 70433
985-892-2422
IMAGE RELEASE FORM
I, said Parent/Legal Guardian, I, said Parent/Legal Guardian, First Last
hereby grant permission to St. Peter Parish Catholic Church, its representatives, employees, and assigns the right to take photographs and/or video recordings of me or the minor children listed below over whom I have legal responsibility as parent or guardian.

Further, I hereby grant permission to St. Peter Parish Catholic Church, its representatives, employees, and assigns to use said photographs and/or video recordings in any legal way deemed appropriate by St. Peter Parish Catholic Church, its representatives, employees, and assignees, including but not limited to use in advertisements, publicity, illustrations, and/or Web content. In so doing, I agree to release, indemnify, and hold harmless St. Peter Parish Catholic Church, its representatives, employees, and assigns from any and all claims for damages on behalf of me or the minor children listed below over whom I have legal responsibility as parent or guardian arising from the publication of my/their names, photograph, or likeness on video recordings as described above.
Terms:

If signing on behalf of a minor child or children as parent or legal guardian, please fill in the name of the minor(s) below:
Name Name First Last
Parent/Guardian's Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY
ROCK Retreat Registration Payment
with shirt $40
without shirt $27
T-shirt size

T-shirt size Youth Small Youth Medium Youth Large Youth X Large Adult Small Adult Medium Adult Large Adult X Large None
You will be redirected to another site for payment once you hit Submit.

If you are not paying by credit card, you must still hit Submit, then close the window. Check or cash must be received at the rectory no later than Monday, June 24th.

ROCK 2019-2020 Retreat Registration

ROCK 2019-2020 Retreat Registration

Terms:

Medical Information and Consent Form

GENERAL INSTRUCTIONS TO PARENTS/GUARDIANS/ADULTS:

SECTION I -- MEDICAL MATTERS -- MANDATORY

SECTION II - EMERGENCY MEDICAL TREATMENT -- MANDATORY

SECTION III - OTHER MEDICAL TREATMENT

SECTION IV - MEDICATIONS SIGN ONLY THOSE OPTIONS THAT ARE APPLICABLE

SECTION V -- MEDICAL INFORMATION

St. Peter Parish Catholic Church 125 E. 19th Avenue Covington, LA 70433 985-892-2422

IMAGE RELEASE FORM

Terms:

ROCK Retreat Registration Payment with shirt $40 without shirt $27

You will be redirected to another site for payment once you hit Submit. If you are not paying by credit card, you must still hit Submit, then close the window. Check or cash must be received at the rectory no later than Monday, June 24th.

SECTION IV - MEDICATIONS

SIGN ONLY THOSE OPTIONS THAT ARE APPLICABLE

St. Peter Parish Catholic Church
125 E. 19th Avenue
Covington, LA 70433
985-892-2422

ROCK Retreat Registration Payment
with shirt $40
without shirt $27

You will be redirected to another site for payment once you hit Submit.

If you are not paying by credit card, you must still hit Submit, then close the window. Check or cash must be received at the rectory no later than Monday, June 24th.