Broom Tree Retreat 2024

Broom Tree Retreat 2024

Youth Registration
General Information
Name*

First NameLast Name
Sex*

MaleFemale
Grade*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parish, Town*
Phone Number*
Retreatant's Email*
Please enter an email that is checked regularly.
Parent/Guardian's Email*
Please enter an email that is checked regularly.
Youth Code of Conduct & Signature
Youth Signature*

Clear
Date*

MonthDayYear

Permission Slip

To be filled out by parent/guardian.
Indemnity Agreement
I, First Name* Last Name* give permission for my child/ward, First Name* Last Name* to participate in the Retreat to be held at Broom Tree Youth & Family Camp, 123 St. Raphael Circle, Irene, SD 57037, March 8-10, 2024. I warrant that my child/ward is in good health. In consideration of my child/ward's participation, I agree to indemnify the parish/school and the Diocese of New Ulm from any claims or lawsuits brought against the parish/school/Diocese of New Ulm by myself, my child/ward, or others that arises out of any behavior by my child/ward at the event/activity described above. I also agree to pay reasonable attorney fee or expenses incurred by the parish/school and the Diocese in defense of such a claim/suit.
I agree that I am responsible for my child/ ward’s conduct and actions. The event sponsor is not responsible for any injury or damage incurred or caused by my child/ward. I understand that my child/ward is required to comply with the Code of Conduct provided by the diocese while participating in the event. I understand that if my child/ward violates the Code of Conduct he/she may be required to be transported home at my expense and I agree to be financially responsible for any damages incurred by my son/daughter while in attendance.
Emergency Medical Treatment
Parent/Guardian Signature

Clear
Video/Photograph Permission
Medical Release Information
My child/ward's birthdate*

MonthDayYear
Date of last tetanus booster

MonthDayYear
Allergies
Only relevant allergies should be listed, such as food and medication allergies, etc.
Medications
Indicate dosage, frequency, etc.
Medical Conditions
Only relevant medical conditions need to be listed.
Insurance Company
Policy Carrier
Policy Number
Emergency Contact Information
Contact #1 Name*

First NameLast Name
Relationship to child/ward*
Contact #1 Phone Number*
Is this number a cell number?*

YesNo
Contact #2 Name*

First NameLast Name
Relationship to child/ward*
Contact #2 Phone Number*
Is this number a cell number?*

YesNo
Signature
Parent/Guardian Signature*

Clear
Date*

MonthDayYear

You're almost done!

We just need one more thing for our records...
How will you be paying?*
NOTE: If you are paying for multiple retreatants, please specify this at checkout.
***Upon registration, you will be redirected to the Broom Tree Retreat registration page and sent a confirmation email.***

The email will contain additional retreat information.
Should be Empty:

Broom Tree Retreat 2024

General Information

Youth Code of Conduct & Signature

Permission Slip

Indemnity Agreement

Emergency Medical Treatment

Video/Photograph Permission

Medical Release Information

Emergency Contact Information

Signature

You're almost done!

***Upon registration, you will be redirected to the Broom Tree Retreat registration page and sent a confirmation email.***

Upon registration, you will be redirected to the Broom Tree Retreat registration page and sent a confirmation email.