2024 Spring Retreat Adult Registration

Please select any food allergies your child has and describe their severity below:

Please list any other food allergies and their severity below:
Below is a question about our Annual Emergency Medical Care Forms.

Note: if your volunteered on the St. Charles fall high school retreat, we already have this information on file, and you can select "Yes". If you are uncertain, please contact Anna Laisure at alaisure@scbfw.org.
Have you completed an Annual Emergency Medical Care Form in the 2023-2024 academic year or since July 1, 2023?*

YesNo

Annual Emergency Medical Care Form
Emergency Contact Information
Emergency Contact 1 Name*

First NameLast Name
Emergency Contact 1 Phone Number*
Please enter a valid phone number.
Emergency Contact 2 Name*

First NameLast Name
Emergency Contact 2 Phone Number*
Please enter a valid phone number.
Consent to Emergency Medical Care
I understand that in an emergency, exigent circumstances may prevent the parish from contacting the above listed emergency contacts immediately, or the parish may be unable to reach them. I therefore consent to the parish taking action which it deems necessary to secure emergency medical care/treatment. I understand that decisions concerning the type of emergency medical care or treatment administered are normally made by health care providers and not by the parish and that exigent circumstances may require the administration of emergency medical care or treatment without my prior consent. However, I have indicated below any treatment preferences I have which the parish may disclose to a health care provider. Participants may complete any of the following:
Preferred Physician
Preferred Dentist
Preferred Hospital
The parish may disclose the following information to a health care provider:

Insurance Company Name: Insurance Company Name

Policy/Group/Claim No.: Policy/Group/Claim No.
Other Medical Facts (ex. allergies, medications)
Signature*

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St. Felix Waiver and Final Signature
Below is a waiver needed by St. Felix.

After completing the waiver, please be sure to scroll to the bottom of this page to provide a final signature and submit.
Thank you for registering as an adult chaperone for our retreat. Please provide your signature below to finalize your registration.
Signature*

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General Information