Holy Spirit Teen ACTS Registration Form 2023 Packet Rev B

Holy Spirit Teen ACTS Registration

What I tell you in the dark, speak in the daylight; what is whispered in your ear, proclaim from the roofs.

Matt 10:27

Retreat Date: June 22 - 25, 2023

Cordi Marion Retreat Center

ACTS is a Catholic retreat movement presented by parishioners for parishioners with the guidance of religious leaders. The goal of each retreat is to facilitate a deepening of our relationship with Jesus Christ, to renew ourselves spiritually, togive new meaning to our prayer life, and to build lasting friendships with members of our parish communities.

This ACTS retreat will begin on Thursday evening, June 22, 2023 and continue through the weekend ending with an 12:00 Mass on Sunday, June 25, 2023 at Holy Spirit Catholic Church at 8134 Blanco Rd, San Antonio, TX 78216. The retreat cost is $225, payable to "Holy Spirit ACTS". Registration begins on Monday, April 3, 2023 and is on a first-come, first-served basis, with a waiting list thereafter. Out of parish registrations will be placed on a waiting list until Monday, May 1, 2023 when all spaces not reserved by Holy Spirit parishioners will be released. To reserve your place, please return this registration form and include a $75 deposit payment. Forms are date and time stamped upon receipt. The $150.00 balance will be due upon check-in Thursday evening at Holy Spirit Catholic Church. **Please note that financial hardship should not prevent anyone from attending the retreat. If you are unable to pay entire fee, contact the parent directors as a limited number of scholarships may be available.

For further information regarding the retreat weekend, please contact the Adult Directors Hanna Reich (210) 341- 1397 or Dan Chavarria (210) 663-5245. A letter will be mailed to registered retreatants 7 10 days prior to the retreat providing you with further details, directions, and suggestions on what to bring for the weekend.

Holy Spirit Teen ACTS Registration: June 22 - 25, 2023

Please print clearly Name (First Last)*

Date of Birth Day*

Date

Name for name tag*

Grade Going into 23-24 school year*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Teen Cell Phone*

Teen Home Phone

Teen Shirt Size:*

Teen Email address*

example@example.com

Parish or Church you attend*

School you attend*

Parent/Guardian Name*

First NameLast Name

Relationship*

(Check if same as above)

Same As Above

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Best Contact Number*

Please enter a valid phone number.

Parent/Guardian Email address*

example@example.com

Does retreatant have any allergies, dietary or special needs during the retreat weekend?*

YesNo

If yes, please specify needs (medical or prescription needs)

I will included my: [ ] *$75 deposit or [ ] $225 retreat fee.*

I will included my $75 depositI will included my $225 retreat fee

Cancellations made within 2 weeks of retreat - full refund of registration fee

Cancellations made within 2 weeks of retreat - $75.00 (deposit will not be returned)

Holy Spirit ACTS Liability Waiver

I, {parentguardianName93} agree on behalf of my child {name94}, to hold harmless and defend Holy Spirit Catholic Church of San Antonio, Texas, the Archdiocese of San Antonio, its officers, agents, employees or representatives associated with the ACTS retreat/trip from any and all liability claims, loss or damages arising from or in connection with my participation in the retreat trip.

Signature*

Clear

Date*

Date

Holy Spirit ACTS Medical Waiver

Please read and list all conditions which apply. All information will be kept confidential.

I hereby warrant that to the best of my knowledge that my child is in good health.
My child I will bring all medications with directions for consumption, including dosage(s) and frequency of consumption.
In the event of an emergency, I hereby give permission to take necessary measures so that my child can be transported to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any treatment by the hospital or doctor.
In the event of an emergency, please contact:

Name*

Relationship*

Home Phone Number

Please enter a valid phone number.

Cell Phone Number*

Please enter a valid phone number.

Name

Relationship

Home Phone Number

Please enter a valid phone number.

Cell Phone Number

Please enter a valid phone number.

Parent/Guardian Signature*

Clear

Date*

Date

Parental/Guardian

Consent Form and Liability Waiver

Participant's Name*

DOB*

Date

Home Address*

City*

State*

Zip Code*

Participant Phone*

Participant Email*

example@example.com

Gender:*

MaleFemale

Grade (2022 - 2023)*

Parent/Guardian Name*

Parent Phone Number*

Please enter a valid phone number.

Emergency phone*

Parent Email

example@example.com

I, {parentguardianName93}, grant permission for my child, {name94} to participate in the Teen ACTS Retreat which requires transportation to a location away from the parish site. This activity will take place under the guidance and direction of parish employees and volunteers from Holy Spirit Catholic

The event information is as follows:

Date: Thu, Jun 22 - Sun, Jun 25, 2023

Type of Event: Teen ACTS Retreat

Place: Cordi Marion Retreat Center

Cost: $225

Event phone contact: Hannah Reich

Telephone number: (210)341-1397

PARENT/LEGAL GUARDIAN'S INITIALS*

OFFICE OF YOUTH MINISTRY

ARCHDIOCESE OF SAN ANTONIO

In consideration for Participant, a minor child, being permitted by Sponsor to participate in the Activity, which includes transportation to and from the Activity, I, being the undersigned and the parent/legal guardian of Participant, hereby acknowledge, consent, and agree as follows:

1.Consent to Participate and to Transportation. I hereby consent to Participant's participation in the Activity. I further consent to the transportation of Participant to and from the Activity by means of the method of transportation designated above.

2.Knowledge of Risks. I acknowledge and agree that I have been advised by Sponsor and that I understand that participation by Participant in the Activity and the transportation of Participant to and from the Activity may involve serious risks. including. without limitation. death. bodily injury. damage to personal property. and dangers resulting from injury or accident. Knowing the risks, dangers, and hazards involved in Participant's participation in and transportation to the Activity. I nevertheless voluntarily consent and agree to Participant's participation in and transportation to the Activity. I. INDIVIDUALLY AND IN MY CAPACITY AS THE PARENT/LEGAL GUARDIAN OF PARTICIPANT. HEREBY EXPRESSLY AND SPECIFICALLY ASSUME FULL RESPONSIBILITY FOR ANY AND ALL RISKS OF DEATH OR BODILY INJURY TO PARTICIPANT OR DAMAGE TO PARTICIPANT'S PERSONAL PROPERTY RESULTING FROM OR ARISING OUT OF (I) PARTICIPANT'S PARTICIPATION IN THE ACTIVITY, OR (II) SPONSOR'S TRANSPORTATION OF PARTICIPANT TO THE ACTIVITY, WHETHER CAUSED BY OR CONTRIBUTED BY THE NEGLIGENCE OF THE SPONSOR. THE ARCHDIOCESE OF SAN ANTONIO (THE "ARCHDIOCESE"), OR ANY OF THEIR RESPECTIVE AFFILIATES DIRECTORS. OFFICERS. AGENTS. EMPLOYEES. VOLUNTEERS. SUCCESSORS AND ASSIGNS (COLLECTIVELY. THE "CHURCH PARTIES" OR OTHERWISE (Initials),

(Initials)*

3. RELEASE AND WAIVER I. INDIVIDUALLY AND IN MY CAPACITY AS THE PARENT/LEGAL GUARDIAN OF PARTICIPANT. HEREBY, RELEASE, WAIVE, AND FOREVER DISCHARGE THE CHURCH PARTIES FROM ANY AND ALL LIABILITY, CLAIMS. LOSSES, JUDGMENTS. DAMAGES. COSTS. EXPENSES. AND DEMANDS OF ANY KIND OR NATURE WHATSOEVER, EITHER IN LAW OR IN EQUITY, RESULTING OR ARISING FROM PARTICIPANT'S PARTICIPATION IN OR SPONSOR'S TRANSPORTATION OF PARTICIPANT TO THE ACTIVITY. I. INDIVIDUALLY AND IN MY CAPACITY AS THE PARENT/LEGAL GUARDIAN OF PARTICIPANT. HEREBY EXPRESSLY ACKNOWLEDGE AND AGREE THAT (I) THIS RELEASE DISCHARGES ALL OF THE CHURCH PARTIES FROM ANY AND ALL LIABILITY THAT PARTICIPANT AND I. INDIVIDUALLY AND IN MY CAPACITY THE PARENT/LEGAL GUARDIAN OF PARTICIPANT. MAY HAVE AGAINST THE CHURCH PARTIES WITH AS RESPECT TO THE DEATH OR BODILY INJURY TO PARTICIPANT OR DAMAGE TO PARTICIPANT' S PERSONAL PROPERTY THAT MAY RESULT FROM (II) PARTICIPANT'S PARTICIPATION IN THE ACTIVITY OR (ID SPONSOR'S TRANSPORTATION OF PARTICIPANT TO THE ACTIVITY: AND (II) THIS RELEASE EXTENDS TO ALL ACTS OF NEGL IGENCE, WHETHER CAUSED BY OR CONTRIBUTED BY ANY OF THE CHURCH PARTIES OR OTHERWISE (Initials)

(Initials)*

4.INDEMNITY I. INDIVIDUALLY AND IN MY CAPACITY AS PARENT/LEGAL GUARDIAN OF PARTICIPANT. UNCONDITIONALLY AGREE TO INDEMNIFY. DEFEND. AND HOLD HARMLESS THE CHURCH PARTIES FROM ANY AND ALL LIABILITY, CLAIMS, LOSSES, JUDGMENTS, DAMAGES, DEMANDS,COSTS AND EXPENSES OF ANY KIND OR NATURE WHATSOEVER, EITHER IN LAW OR IN EQUITY. (INCLUDING. WITHOUT LMITATION. COURT COSTS AND ATTORNEY'S FEES) INCURRED BY ANY OF THE CHURCH PARTIES RESULTING OR ARISING FROM (I) PARTICIPANT'S PARTICIPATION IN THE ACTIVITY. OR (II) SPONSOR'S TRANSPORTATION OF PARTICIPANT TO THE ACTIVITY, INCLUDING, WITHOUT LIMITATION, THE DEATHOR BODILY INJURY TO PARTICIPANT OR DAMAGE TO PARTICIPANT'S PERSONAL PROPERTY THAT MAY RESULT FROM (1) PARTICIPANT'S PARTICIPATION IN THE ACTIVITY OR (II) SPONSOR'S TRANSPORTATION OF PARTICIPANTTQ THE ACTIVITY. WHETHER CAUSED BY OR CONTRIBUTED BY THE NEGLIGENCE OF ANY OF THE CHURCH PARTIES OR OTHERWISE. (Initials)

(Initials)*

5. Medical Authorization In the event of any injury or illness of Participant during the Activity, 1 hereby authorize and consent to the transportation of Participant to the nearest medical or dental facility. and, should the need arise. I hereby further authorize and consent to any x-ray, examination, anesthetic, medical or surgical diagnosis and treatment in the discretion of the attending physician or dentist. I understand that I am giving this authorization in advance of any specific diagnosis, treatment or hospital care being required and I am providing this authorization to give authority and power to render any care which the medical provider and/or dental provider deems advisable. None of the foregoing medical or dental treatments shall be withheld if I cannot be reached prior to the administration of such medical and/or dental treatments. I hereby agree that I shall be solely responsible for the payment of any and all costs for such medical and/or dental treatment of Participant, and in no event shall any of the Church Parties be required to pay for any such costs or expenses. I, INDIVIDUALLY AND IN MY CAPACITY AS THE PARENT/LEGAL GUARDIAN OF PARTICIPANT. HEREBY, RELEASE, WAIVE, AND FOREVER DISCHARGE THE CHURCH PARTIES FROM ANY AND ALL LIABILITY. CLAIMS, LOSSES, JUDGMENTS. DAMAGES. COSTS. EXPENSES, AND DEMANDS OF ANY KIND OR NATURE WHATSOEVER, EITHER IN LAW OR IN EQUITY, RESULTING OR ARISING FROM ANY SUCH MEDICAL OR DENTAL TREATMENT RENDERED TO PARTICIPANT.

PARENT/LEGAL GUARDIAN'S INITIALS*

6. Photo/Video Consent and Release. I hereby authorize Sponsor and the Archdiocese to take photographs, recordings. and/or videos (whether electronic, digital, or otherwise) of Participant in connection with the Activity, and I hereby consent to the use, reproduction, and publication of such images by Sponsor and the Archdiocese in connection with the promotion and publicity of the activities of Sponsor and the Archdiocese, including, without limitation, publication of such images on Sponsor's website. I. individually and in my capacity as parent/legal guardian of Participant, hereby waive any right to inspect or approve the actual use by Sponsor or the Archdiocese of any such image of Participant. Such images of Participant shall be the sole property of Sponsor. and I. individually and in my capacity as parent/legal guardian of Participant, acknowledge and agree by that neither I nor Participant shall be entitled to any compensation whatsoever should any such images of Participant be used Sponsor or the Archdiocese. (Initials)

PARENT/LEGAL GUARDIAN'S INITIALS*

7. COVENANT NOT TO SUE. I HEREBY ACKNOWLEDGE AND AGREE THAT I. INDIVIDUALLY OR IN MY CAPACITY AS PARENT/LEGAL GUARDIAN OF PARTICIPANT. WILL NOT INSTITUTE ANY SUIT OR ACTION AT LAW. OR OTHERWISE, AGAINST ANY OF THE CHURCH PARTIES OR INITIATEOR ASSIST IN THE PROSECUTION OF ANY CLAIM FOR DAMAGES, OR CAUSES OF ACTION. WHICH I. INDIVIDUALLY AND/OR IN MY CAPACITY AS PARENT/LEGAL GUARDIAN OF PARTICIPANT, MAY HAVE BY REASON OF INJURY OR DEATH TO PARTICIPANT OR DAMAGE TO PARTICIPANT'S PERSONAL PROPERTY RESULTING OR ARISING FROM PARTICIPANT'S PARTICIPATION IN THE ACTIVITY OR SPONSOR'S TRANSPORTATION OF PARTCIPANT TO THE ACTIVITY. (Initials)

PARENT/LEGAL GUARDIAN'S INITIALS*

8. Severability. If any term. covenant. or condition of this Parental/Guardian Permission, Release, and Waiver of Liability (the "Agreement") is, to any extent, invalid, illegal, or unenforceable, I hereby agree that the remainder of this Agreement shall not be affected thereby. and shall, notwithstanding, remain binding. valid and enforceable to the fullest extent permitted by law.

ICOVENANT. CERTIFY AND REPRESENT TO SPONSOR THAT I AM THE PARENT/LEGAL GUARDIAN OF PARTICIPANT AND THAT I HAVE FULL LEGAL AUTHORITY TO ENTER INTO THIS AGREEMENT ON BEHALF OF PARTICIPANT. I HAVE (I) FULLY READ THIS AGREEMENT. (II) FULLY UNDERSTAND ITS TERMS. AND (III) AGREE TOBE BOUND BY ALL OF THE TERMS AND CONDITIONS CONTAINED HEREIN. I UNDERSTAND THAT I. ON MY OWN BEHALF AND ON BEHALF OF PARTICIPANT. HAVE GIVEN UP SUBSTANTIAL LEGAL RIGHTS BY SIGNING THIS AGREEMENT I. INDIVIDUALLY AND IN MY CAPACITY AS PARENT/LEGAL GUARDIAN OF PARTICIPANT. SIGNED THIS AGREEMENT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. ASSURANCE OR GUARANTEE BEING MADE TO ME BY ANY OF THE CHURCH PARTIES. I INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE BY ME AND PARTICIPANT OF ALL LIABILITY AGAINST THE CHURCH PARTIES TO THE FULLEST EXTENT PERMITTED BY APPLICABLELAW.

Signature of Participant's Parent/Legal Guardian*

Clear

Date*

Date

Printed Name of Participant's Parent/Legal Guardian*

PARENT/LEGAL GUARDIAN'S INITIALS*

MEDICAL INFORMATION & EMERGENCY CONTACT

If you are unable to reach me, please contact: Name:

Name*

Relationship to me or my son/daughter*

Relationship to me or my son/daughter: Home Phone: ( ) Cell Phone: ( )

Home Phone Number

Please enter a valid phone number.

Business Phone Number

Please enter a valid phone number.

Cell Phone Number*

Please enter a valid phone number.

Please include a photocopy of your Insurance Card, front and back. Insurance Carrier: Policy Number:

Insurance Carrier*

Policy Number*

My son/daughter is taking medication and will bring all medication with him/her and it will be clearly labeled. My son/daughter is taking the following medications) and directions for taking this medication, including dosage, frequency and storage are as follows:

I hereby grant permission for non-prescription medication (such as cough drops, cough syrup, Tylenol, etc.) to be given to my child if necessary. I understand that aspirin will not be given to my son/daughter without my express permission: I grant such permission*

YesNo

My son/daughter is taking medication and will bring all medication with him/her and it will be clearly labeled. My son/daughter is taking the following medications) and directions for taking this medication, including dosage, frequency and storage are as follows:

I hereby grant permission for non-prescription medication (such as cough drops. cough syrup. Tylenol. etc to be given to my child if necessary. I understand that aspirin will not be given to my son/daughter without my express permission: I grant such permission No. Yes,

My son/daughter is allergic to the following: My son/daughter's immunizations are current and up to date My son/daughter has the following limitations:

My son/daughter is allergic to the following

My son/daughter's immunizations are current and up to date

YesNo

My son/daughter has the following limitations

My son/daughter experiences homesickness, emotional reactions to new situations, sleepwalking. fainting. bedwetting, etc. Yes, No. Please explain:

My son/daughter experiences homesickness, emotional reactions to new situations, sleepwalking, fainting, bedwetting, etc.*

YesNo

Please explain

Parent/Guardian Name (PRINT)*

Signature*

Clear

Date*

Date

FINANCIAL ARRANGEMENT OPTIONS (Please check one option):*

FULL PAYMENT OPTION ($225)TWO CHECKS OVER TWO MONTHS (1st $75 due with application and 2nd before retreat)

PARENT/LEGAL GUARDIAN'S INITIALS

*MUST LIST AT LEAST ONE ALTERNATE / EMERGENCY CONTACT