Steubenville Student Liability Form

Student Participant Name*

First NameLast Name

MaleFemale

Student Participant Email *

example@example.com

Student Participant Cell

Please enter a valid phone number.Format: (000) 000-0000.

Student Participant Birthday*

Date

0123+

What school do you attend? (i.e. homeschooled, CHS, etc)

Parent/Guardian Name*

First NameLast Name

Parent Cell*

Please enter a valid phone number.Format: (000) 000-0000.

Parent Email*

example@example.com

Parish Affiliation*

YesNoPlease text parent instead

Picture of Participant (headshot) *

Type of event: Steubenville Youth Conference June 26th - 30th

Destination of event: Joliet, IL

Individuals in charge: Tricia Walz, Kelli Kleinschnitz

Estimated time of departure and return: Meet at Saint Mary Help of Christians on Thursday, June 26th around 7:30 am & returning to Saint Mary Help of Christians on Monday, June 30th around 4:30pm.

Mode of transportation to and from event: Coach buses from Trobec’s bus service

I, parent/guardian, grant permission for my child, child's name* to participate in the Steubenville Conference trip that requires transportation to a location away from the parish site. This activity will take place under the guidance and direction of parish employees and/or volunteers from the "Illuminate Youth Ministry Group" which consists of the following 3 Area Catholic Communities (All Called to Christ, Together As One and Holy Saints respective parishes).

As a parent and or legal guardian, I remain legally responsible for any personal actions taken by the above teen minor. I agree on behalf of myself, my child named here and, or our heirs, successors, and the signs, to hold harmless and defend the church of Saint Augustine, Christ Church Newman, St. Mary Help of Christians, it’s officers, directors, employees and agents, and the diocese of Saint Cloud, it’s employees and agents, chaperones, or representatives associated with the event, from any claim arising from or in connection with my child attending the event or in connection with any illness or injury including death or cost of medical treatment in connection with there with, and I agree to compensate the parish, it’s officers, directors and agents, and the Diocese of St. Cloud, it’s employees and agents and chaperones, or representatives associated with the event for reasonable attorneys fees and expenses which may incur if any action brought against them as a result of such injury or damage, unless such claims arise from the negligence of the parish/diocese.

Signature*

Date*

Date

Emergency Contact*

First NameLast Name

Emergency Contact Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Family Doctor*

First NameLast Name

Family Doctor Phone:*

Please enter a valid phone number.Format: (000) 000-0000.

Family Health Plan Carrier Information:*

CarrierPolicy #

Medical matters: I hereby warrant that to the best of my knowledge, my child is in good health, and able to participant in the trip activities that include walking, sitting for long periods of time, and other recreational activities.

Emergency medical treatment: In the event of an emergency, I hereby give permission to transfer 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.

Parent Signature*

Date*

Date

Medications: My child is taking medications at the present time. My child will bring all such medications necessary, and such medications will be well-labeled. Names of Medications and concise directions for seeing that the child takes such medications, including dosage and frequency, are as follows:

Please sign either #1 or # 2

1 . NO medication of any type, whether prescriptions or non- prescription, may be administered to my child unless the situation is life- threatening and emergency treatment is required.

Signature
Date

2 . I hereby grant permission for non-prescription medication (such as non-aspirin products, i.e. acetaminophen or ibuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.

Signature
Date

Specific Medical Information: The parish will take reasonable care to see that the following information will be held in confidence. Fill out if applicable or else type NA if not applicable:

Allergic Reactions: Please list any allergies we should be aware of. If your child has a specific medication for severe allergies, please provide explanation of drug, dose etc. (Food, medicine, or environmental allergies)

Please list any other concerns you would like us to be aware for your child (whether medical or emotional). Leave blank if not applicable:

Photo Release: I give permission for the " All Called to Christ" "Holy Saints" Area Catholic Communities and Illuminate Youth Ministries to take individual or group pictures of the youth listed above. All copies of these pictures are the properties of the "All Called to Christ" "Holy Saints" Area Catholic Community and can be used on flyers, websites, posters, bulletins, and social media sites such as Facebook, Instagram, etc.

Signature*
Date*

Youth Participant Code of Conduct

1. All adult and youth participants may not use or possess alcoholic beverages, vaping, tobacco products, and/or any other illegal drug or substance. Participants may not use or possess any type of weapon or instrument that could be used as a weapon.

2. Participants are required to follow the schedule and participate in programs and activities unless exempted for medical reasons.

3. Participants and their parents/guardians will be responsible to make restitution for any damages they cause to properties utilized as part of the event. This includes graffiti and/or the physical damage to the facilities and the property of others.

4. Participants will not tamper with smoke detectors, fire extinguishers, fire alarms or any other emergency equipment. The tampering of such items is considered a misdemeanor and is punishable by law.

5. Participants are not allowed in the dorm rooms of the opposite gender apart from small group meeting time and with the supervision of parish chaperones. Inappropriate sexual contact is not allowed. Hotel rooms must remain clean and undamaged.

6. Participants are never allowed in the restrooms or changing rooms of persons of the opposite gender.

7. Participants will agree to abide by all rules established by the Leaders, chaperones and Partnership for Youth, including lights out times, quiet time, and other such rules, including health-related guidance.

8. Harassment in any form will not be tolerated.

9. Participants shall agree to respect the role of adult leaders in promoting and administering the above rules and regulations.

10. Youth participants will be allowed cell phones at designated times. Parish leaders may collect phones as needed and from time-to-time. Cell phones may not be used in a manner that would violate our Christian ethics or in a distracting/disruptive manner. Parish leaders will return any collected phones at the end of the event.

11. Limited use of other electronic devises may be allowed. Music, videos, etc... need to be within the parameters of Catholic teaching. These devises may not be used during organized sessions or in a distracting/disruptive manner. No gaming systems will be allowed

Consequence Policy: All youth are expected to follow the above outlines expectations, directions of security and conference staff. Any instances of transgression of these policies, lack of cooperation or insubordination will be subjected to appropriate discipline and/or fines. Failure to comply may result in immediate dismissal of the participant, at the expense of the individual.

STUDENT Participant Signature*

Date*

Date

PARENT Signature*

Date*

Date

Student Liability Form

Health & Medical Information: