• Year 2 Confirmation Fall Retreat Permission Form

    November 19-21, 2021

  • Welcome to Holy Name of Mary's Online Registration for the Year 2 Confirmation Retreat!

    We are excited to have your Year 2 Confirmation Teen join us for our overnight weekend at Salvation Army's Pine Summit Camp in Big Bear.

    Year 2 Confirmation Retreat

    November 19-21, 2021

    Pine Summit Salvation Army Camp

    700 Wren Dr, Big Bear Lake, CA 92315

    Cost: $230


    For your convenience, our registration for this year is 100% digital.

    COVID-19 Protocol & Testing
    *These protocols are subject to change at the discretion of the LA Archdiocese and LA and San Bernardino County Guidelines

    • Proof of Negative COVID-19 Test - All retreat participants and volunteers are required to show proof of a negative PCR molecular COVID-19 test taken within 3 calendar days at the time of check-in on Friday, November 19th, regardless of vaccination status . Note that rapid tests, antigen tests, and antibody tests are not accepted.  
    • Mask Requirement - Consistent with L.A. County Public Health and CDC guidance, all participants and volunteers will be required to wear a face mask at all times. Masks must be tight-fitting, multi-ply masks, surgical masks, or KN95 masks. Gaiters, bandanas, thin fabric coverings, and valved masks are not approved. 
    • Health Screening - Participants may be screened for symptoms of COVID-19 at the time of check-in. Anyone that has a fever or other symptoms of COVID-19 will not be allowed to attend the retreat and will need to immediately remove themselves from the premises.


    *If you have more than one teen attending, please fill out the form again for each teen.

  • Year 2 Confirmation Fall Retreat Form

    Holy Name of Mary Parish; San Dimas, CA

  • Teen Participant Information

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  • Parent/Guardian Contact Information

  • Emergency Contact Information

    *Additional Person to Contact if Parent Cannot Be Reached

  • Medical/Health Information

    • MEDICATION AUTHORIZATION FORM (please click this dropdown menu and complete if child needs ANY medication during event; this includes epi-pens, inhalers, insulin, etc)  
      • Medication administered at the retreat location must be:
        • In its original container with the original label
        • Sealed in a plastic bag w/ participant's name attached
      • Because of the risk of students sharing medications, students may not carry medication of any kind to be self-administered at the retreat location. If a student is seriously at risk without an EpiPen or inhaler on his or her person, the student may receive special consideration.
      • Medication shall be in an appropriate container and be kept with the designated nurse chaperone. The teen shall go to the nurse chaperone on-site for medication during mealtimes or as needed.
      • A teen may not be given medicine prescribed for family members.
      • These medication regulations apply to both prescription and non-prescription medications.

    • Permission for Administration of Medication and/or Testing at Retreat: I request that my son/daughter identified above, be permitted to carry and use emergency medication (inhaler, epi-pen, insulin, etc.) and/or test for levels of blood sugar at the Location identified above as prescribed by the physician above. I acknowledge and understand that no health care professional or other trained adult may be available at the Location or at the field trip/event/activity to assist, monitor or supervise my son/daughter’s self-administration of medication or testing unless arrangements have been made in advance. In the event that my son/daughter is unable to self-administer or self-test, I agree that Location staff/chaperones may assist my son/daughter to the extent possible under the circumstances, but neither they nor the Location shall be liable for any adverse consequences or injury. I hereby give the Location staff/chaperones permission to call paramedics to render treatment to my son/daughter should that be necessary and to release medical information to first responders for that purpose. For all other medications, my son/daughter and I will comply with the Location’s policies and procedures and will provide the Location with any medication my son/daughter requires in its original prescription bottle.

             
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  • Year 2 Confirmation Fall Retreat Form

    Holy Name of Mary Parish; San Dimas, CA

  • Consent & Release of Liability
    I hereby give my permission for my child's participation in the Year 2 Confirmation Retreat on November 19-21, 2021, sponsored by Holy Name of Mary Church on the date indicated. I agree to direct my teen to cooperate with the directions of parish personnel and volunteers responsible for this activity.

    As a condition of participating in this activity, I hereby hold harmless, release and discharge The Roman Catholic Archbishop of Los Angeles, a corporation sole, Archdiocese of Los Angeles Education & Welfare Corporation, Holy Name of Mary Church, and the Congregation of the Sacred Hearts of Jesus and Mary, their respective agents and employees and any parent/volunteer/chaperone, from any and all liability, loss or claims for personal injuries, wrongful death or property damage that I or my child may suffer as a result of participation in the Faith Formation program.

    I hereby authorize Holy Name of Mary Church to use my child’s image, voice, name and/or work (“Personal Information”). I grant permission for photographs and/or videos of my child(ren) to be taken during activities and possibly used for noncommercial purposes including, but not limited to, publicity or promotion in print (e.g. in the bulletin or church displays), electronic media, such as the church AV system, social media and/or on the Holy Name of Mary website.

    I give permission to the responsible staff members, chaperones, medical practitioners and medical facilities to use their judgment in obtaining and providing medical treatment for my child should it become necessary to do so. I understand that health insurance benefits through Holy Name of Mary Church, if any, may have limited application, and that I am entirely responsible for the cost of all medical treatment provided to my child. I agree to reimburse Holy Name of Mary Church for the cost of any medical treatment and related expenses incurred.

    I acknowledge the following (please check the boxes after reading):
    *
    *
    * 

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