2018 Spring Retreat Registration Form

2023-24 Life Teen Registration From
Contact person for Life Teen: Tracy Melin

Email: tmelin@bsctlh.com

Sundays 6:00-7:45 pm

Please submit one form per teen
Student Name*

First NameLast Name
Grade for 2022-23*
Birth Date*

MonthDayYear
Sex*
School*
What church do you attend?*
Father's Name*
Father's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mother's Name*
Mother's Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Lives with

MotherFatherBoth
Parent's Preferred E-mail*
Mother's Cell Phone*

Area CodePhone Number
Father's Cell Phone *
Home Number

Area CodePhone Number
MEDICAL INFORMATION Please list all information pertaining to allergies, diet, special medications, health conditions or any other information necessary in an emergency situation. Explain fully:
Medications and dosage my child is taking:
Use a separate line for each medication
Insurance Carrier:*
Name of Policy Holder*
Relation to Youth*
Policy Number*
Group Number*
PERMISSION

If you would like your youth to participate in this event, please sign and return the following statement of consent and release of liability. As parent or legal guardian, you remain fully responsible for any legal responsibility which may result from any personal actions taken by your youth.

I hereby consent to participation by my youth, in the event described above. I understand that this event will take place away from the parish grounds and that my youth will be under the supervision of the designated supervisor on the stated dates. I further consent to the conditions stated above on participation in this event, including the method of transportation.

In consideration for the opportunity for my child to participate, and fully recognizing that such an undertaking involves an element of risk, we assume all risks and hazards incidental to such participation and do hereby release, absolve, indemnify and agree to hold harmless the Diocese of Pensacola-Tallahassee and Blessed Sacrament Parish, and their employees, agents, volunteers, and other persons acting on their behalf. Neither the Diocese of Pensacola-Tallahassee, Blessed Sacrament Parish, nor said agents, employees, or volunteers, shall be held financially responsible for any injury, illness or death incurred as a direct or indirect result of this activity. We the undersigned have read this release and understand all its terms and execute it voluntarily and with full knowledge of its significance.

EMERGENCY MEDICAL TREATMENT:

In the event of an emergency, I/we hereby authorize the Diocese of Pensacola-Tallahassee, and Blessed Sacrament Parish, through its authorized representatives, to transport my child to a hospital or other doctor’s office or medical facility for emergency medical attention. I/We additionally authorize such representatives of the Diocese and/or School to obtain and give consent to whatever medical treatment the representative deems necessary, including the administering of anesthetic and surgery, and do hereby release the Diocese and Blessed Sacrament Parish, and their authorized representatives from any and all claims which may arise from the above-referenced obtaining and consenting to medical treatment. I/We wish to be advised, if possible, prior to the providing of any non-emergency medical treatment by any physician or hospital.

If I/we are unable to be reached, please contact the following:
Emergency contact and relation to participant*
Phone Number *
Sacraments Received

BaptismReconciliationEucharistConfirmation
Parent or Guardian Permission for Direct Contact With Minors

This form allows you to identify who may communicate with your minor children and by what means. Parents and guardians may choose to be included in all written or text-based communications except those that occur on an official social networking site or online community administered and maintained by the ministry, parish, or school pursuant to the terms of diocesan policy and approved by parents or guardians on this form.

Blessed Sacrament Life Teen communicates via:
- Cellular Phone: Remind App (Blessed Sacrament Life Teen)
- Email: Flocknote; Jonathan Shea (jshea@bsctlh.com); Tracy Melin (tmelin@bsctlh.com)
- Social Media Sites: Blessed Sacrament Life Teen & Edge (Facebook) Blessed Sacrament Life Teen (Instagram) Blessed Sacrament Edge (Instagram)
Blessed Sacrament EDGE may contact my child directly*

YesNo
Contact with my child is permissible via the following methods:

Call/Voice MessageText MessageBlessed Sacrament Life Teen & Edge (Facebook)Blessed Sacrament Life Teen (Instagram)Blessed Sacrament EDGE (Instagram)
Teen'sPhone Number

Area CodePhone Number
Teen's E-Mail Address
example@example.com
Finally, I/we hereby give permission for Blessed Sacrament, to use the name of my child and/or his/her photograph for promotional purposes in print and/or electronic media for the parish.
Sign Here:*

Clear
Should be Empty:

2023-24 Life Teen Registration From