St. Cecilia Catholic Church · SUMMER 2024 JUNIOR HIGH CAMP

Father’s Name:

First Name

Last Name

Day Phone:

Mother’s Name:

First Name

Last Name

Day Phone:

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Home Phone

Alternate Phone

Email

Verify Email

Participant’s Name

First Name

Last Name

Date of Birth

(mm/dd/yyyy)

Age

Grade in Fall of 2024

Sex

T-Shirt Size (Adult Size)

*

(Please Select one)

Parish or Catholic School

CONSENT & LIABILITY WAIVER

Important! To be filled out by the Parent/Guardian for youth under 18 years of age. (If the participant is 18 years of age or older, consent must be signed by the individual)

*

In consideration of my child’s participation in this event, I agree on behalf of myself, my child named herein, and our heirs, successors, and assigns to indemnify, hold harmless and defend the Archdiocese of Galveston-Houston, the sponsoring parish, its pastor, youth ministry leader, principal, other agents, employees or other representatives associated with the event from any and all injuries, losses or claims arising out of my child’s participation in the event.

Agree

YOUTH PARTICIPANT

*

In checking the box below, I agree to abide by any/all policies and rules established for this event/activity (see Code of Conduct). Should I not be able to maintain the guidelines and expectations of the adults and my peers, I understand that there will be consequences for my actions, including being removed from the activity and being sent home at my parent’s expense.

Agree

VIDEO/PHOTOGRAPHY CONSENT

*

As parent/guardian, I understand that promotional pictures and videos (individual and group) will be taken during this event. By checking the agree box below I give permission for my son’s/daughter’s picture to be used for promotional materials (newsletter, web page, calendars, power point, video, etc.) in highlighting the event.

Agree

By submitting this form, I certify that all information contained herein is true and accurate to the best of my knowledge.

MEDICAL CONSENT FORM

Medical Matters

I hereby warrant 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 in accordance with your wishes:

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 and I understand that all financial obligations are my responsibility.

In the event of an emergency and you are unable to reach me, contact:

Name

First Name

Last Name

Relationship

Phone

Family Doctor

Phone

Medications

My child will bring all such medications, well labeled, that are necessary. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency are as follows

My child is taking the following medication at the present time.

Medication(s), Dosage and Administer:

CHOOSE ONE

Medical Conditions Information

(Archdiocesan personnel will take reasonable care to see that the following information will be held in confidence.)

My son/daughter has:

Has had an episode of the following or has been diagnosed:

Seizures

Asthma

Diabetic

Allergic reactions to the following (foods, dyes, latex etc.)

Has a medically prescribed diet?

The following physical limitations?

Immunizations current and up to date:

Yes

No

You should also be aware of these special medical conditions of my child (e.g. depression, anxiety, etc.):

Date of last tetanus/diphtheria immunization

Insurance Information:

Do you carry medical insurance at this time?

Insurance Carrier:

Insurance Policy Number:

*

In the event it comes to the attention of the chaperones associated with the activity that my child becomes ill with repeated symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called immediately. If this will be a long distance call, I want to be called collect (with phone charges reversed to myself). I fully understand the foregoing statements and sign this Parental/Guardian Medical Consent Waiver knowingly, freely, and willingly.

Agree

Register Another Child

Yes

No

Participant’s Name Additional

First Name

Last Name

Date of Birth

(mm/dd/yyyy)

Age

Grade in Fall of 2024

Sex

T-Shirt Size (Adult Size)

*

(Please Select one)

Parish or Catholic School

CONSENT & LIABILITY WAIVER

Important! To be filled out by the Parent/Guardian for youth under 18 years of age. (If the participant is 18 years of age or older, consent must be signed by the individual)

*

In consideration of my child’s participation in this event, I agree on behalf of myself, my child named herein, and our heirs, successors, and assigns to indemnify, hold harmless and defend the Archdiocese of Galveston-Houston, the sponsoring parish, its pastor, youth ministry leader, principal, other agents, employees or other representatives associated with the event from any and all injuries, losses or claims arising out of my child’s participation in the event.

Agree

YOUTH PARTICIPANT

*

In checking the box below, I agree to abide by any/all policies and rules established for this event/activity (see Code of Conduct). Should I not be able to maintain the guidelines and expectations of the adults and my peers, I understand that there will be consequences for my actions, including being removed from the activity and being sent home at my parent’s expense.

Agree

VIDEO/PHOTOGRAPHY CONSENT

*

As parent/guardian, I understand that promotional pictures and videos (individual and group) will be taken during this event. By checking the agree box below I give permission for my son’s/daughter’s picture to be used for promotional materials (newsletter, web page, calendars, power point, video, etc.) in highlighting the event.

Agree

By submitting this form, I certify that all information contained herein is true and accurate to the best of my knowledge.

MEDICAL CONSENT FORM

Medical Matters

I hereby warrant 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 in accordance with your wishes:

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 and I understand that all financial obligations are my responsibility.

In the event of an emergency and you are unable to reach me, contact:

Name

First Name

Last Name

Relationship

Phone

Family Doctor

Name of Insured:

First Name

Last Name

Phone

Medications

My child will bring all such medications, well labeled, that are necessary. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency are as follows

My child is taking the following medication at the present time.

Medication(s), Dosage and Administer:

CHOOSE ONE

Medical Conditions Information

(Archdiocesan personnel will take reasonable care to see that the following information will be held in confidence.)

My son/daughter has:

Has had an episode of the following or has been diagnosed:

Seizures

Asthma

Diabetic

Allergic reactions to the following (foods, dyes, latex etc.)

Has had a medical surgery within the last six months?

Yes

No

Has a medically prescribed diet?

The following physical limitations?

Immunizations current and up to date:

Yes

No

Date of last tetanus/diphtheria immunization

You should also be aware of these special medical conditions of my child (e.g. depression, anxiety, etc.):

*

In the event it comes to the attention of the chaperones associated with the activity that my child becomes ill with repeated symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called immediately. If this will be a long distance call, I want to be called collect (with phone charges reversed to myself). I fully understand the foregoing statements and sign this Parental/Guardian Medical Consent Waiver knowingly, freely, and willingly.

Agree

Amount *	Quantity
$150