Christ Power 2023

ChristPower 2023 Registration Form

Please carefully fill in the form below. It is a bit long, but it's for the safety of your teen! Thank you in advance!
Participant Full Name*

First NameLast Name
Participant Phone Number*

Area CodePhone Number
Participant E-mail*
Gender*
Birthday (MM/DD/YYYY)*
What grade are you entering in the fall?*
T Shirt Size*

Parent Contact(s)
Parent Name*

First NameLast Name
Parent Email (this is the primary email I will use to keep in contact with you leading up to the retreat)*
example@example.com
Parent Phone Number (this is the primary number I will use to keep in contact with you leading up to the retreat)*

Area CodePhone Number
Parent Name

First NameLast Name
Parent Phone Number

Area CodePhone Number
Parent Email
example@example.com

Emergency Contact

(other than parents)
Name*

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Participant*

Medical
Any special dietary requirements, medical history, medication or major allergies? *
Do you grant permission to adult chaperones to give my child non-prescription drugs (Tylenol, etc.) in the event circumstances reasonably demonstrate that my child is in need of such drugs?*

I DOI DO NOT
I hereby authorize any adult chaperone to consent to any medical treatment of the named youth, which, in the judgment of recognized medical facility, under the general or special supervision of a licensed physician, may be deemed necessary.
Parent Signature*

Clear

Code Of Conduct

Teens will need to read this page and sign.
First and foremost, you are Christian ladies and gentlemen; you are disciples of Jesus Christ, and you are representing your Parish

General Guidelines:
• Always follow the instructions of your chaperones, high school teens, adult leaders, and youth minister.
• Be sure to meet with your small group at the designated times and locations. Do not go anywhere by yourself or without telling one of the leaders.
• Respect others in what you do and say.
• Respect the facility by picking up after yourselves and only using the spaces and supplies provided.
• Dress modestly.
• No “purpling” which would imply no guy and girl physical contact of any kind.
• Electronics only to be used during appropriate times, as designated by the youth minister or core team members.
• Absolutely no illegal drugs, alcohol, weapons or tobacco products of any kind.

I have read and understood the expectations and guidelines for this event and will cooperate with these rules. I understand that failure to comply may result in immediate dismissal, with transportation home by my parents
Teen Signature*

Clear
Parent Signature*

Clear

Transportation Permissions
The worksites will be off of St. Anselm's campus, where we are staying for the week, and will require driving. Please check all that you are comfortable with.
I give my teen permission to ride in the car of an adult volunteer.I give my teen permission to ride in the car of another teen.I give my teen permission to drive themselves.I give my teen permission to drive other teens in his/her car.
As parent or legal guardian, you remain fully responsible for any legal responsibility which may result from any personal actions taken by the named student.
Parent Signature*

Clear

Agreements
1. As the parent or guardian of the teen stated aboved, in signing this form, I hereby state that the information included in this form is correct and give permission for my child to participate in the activity described on this form.

2. I understand that my child will be under the supervision of the Archdiocese of St. Louis Parishes staff and volunteers.

3. I recognize that there are risks inherent in participation in any activity and agree to hold Archdiocese of St. Louis Parishes, its affiliates and its and their employees, volunteers and agents, harmless from any injury to my child or damage to or loss of personal property of my child not caused by the negligence or misconduct of Archdiocese of St. Louis Parishes, its affiliates and its and their employees, volunteers and agents.

4. In the case of a medical emergency, I understand that every effort will be made to contact me, but in the event that I cannot be reached, I hereby give permission for my child to be evaluated, diagnosed and treated in accordance with standard medical practice by licensed medical personnel.

5. I hereby give permission to the Archdiocese of St. Louis Parishes to use any photographs or video footage taken of my child in
print and on their website for promotional purposes.

6. I understand that for all Youth Ministry activities there is a zero tolerance policy for the use of any mood altering
chemicals (including alcohol and illegal drugs), foul language, threats or any type of abuse and inappropriate physical contact. I agree to follow this policy.

7. I recognize that this week requires full participation and that leaving for other events is prohibited.
Signature*

Clear
By signing this form, I acknowlege that my registration is not complete until I turn in the payment.

If payment is turned in before June 1st, the cost is $250.00.

Anything on June 1st or past, the cost is $275.00.

Registration is a hard deadline of June 10th. No exceptions.

Please make checks payable to St. Anselm and turn in to your respective youth minister.
What parish are you from?*
Should be Empty:

ChristPower 2023 Registration Form

Parent Contact(s)

Emergency Contact

Medical

Code Of Conduct

Transportation Permissions

Agreements