2025 Steubenville Mid America OLS Permission Form

2025 Steubenville Mid America with OLS Life Teen

July 18-20
Purpose of the Event: Grow in Faith

Departure Time & Location: Friday July 18 5:15am arrival to load bus for 5:30am departure from Our Lady of Sorrows

Return Time & Location: Sunday July 20th 11:00pm pm return to Our Lady of Sorrows

Adult in Charge: Grant Wyatt

Phone: 205-281-8079

Confernce Location: Missouri State University; 901 S. National Ave.
Springfield, MO 65897

Hotel Location: Holiday Inn Express & Suites Springfield North; 3050 North Kentwood Avenue, Springfield, MO 65803, USA

Mode of Transportation: Departing and returning from OLS on OLS Buses

Cost: $200; with a $75 non-refundable deposit to hold spot

Checks can be made out to OLS Youth

Teen Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Grade (entering in 2025)
Sex

MaleFemale
T-Shirt Size
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name

First NameLast Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Alternate Emergency Contact

First NameLast Name
Alternate Contact Phone Number
Please enter a valid phone number.
I grant permission for my child {teenName} to participate in the event described above.

I agree on behalf of myself, my child {teenName}, our heirs, successors, and assigns to hold harmless and defend the Diocese of Birmingham in Alabama, its Bishop, Parishes, Employees and Volunteers from any liability for illness, injury or death arising from or in connection to my child’s attendance at the event described above.

To the best of my knowledge, my child {teenName} is in good health, I assume all responsibility for the health of my child. In the event of an emergency, I give permission to transport my child for emergency treatment. I wish to be advised prior to any treatment by a hospital, clinic or doctor. I have noted any and all health/diet concerns on the second page of this form.

As parent/legal guardian, I remain legally responsible for any actions taken by my child {teenName}. My child will conduct himself/herself in a proper and respectful manner. I understand that failure to abide by standard codes of conduct will cause my child to be dismissed from the above named event. I agree that if my child is dismissed from the event I will travel (or send an adult designee) at my expense to the event location and retrieve my child.
Media Permission I give my permission for my child (named herein) to be photographed and/or recorded at the event described herein and understand that media produced may be used to advertise or promote future

YesNo
Signature

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Medical Information
Family Physician
Physician Phone Number
Please enter a valid phone number.
Health Plan Carrier
Policy/Contract Number
Name of Policy Holder
My child is taking medication at present. He or She will bring all medications necessary, and such medications will be well labeled. Names of medications and instructions
Optional Instruction: Do not give non-prescription medication of any kind to my child without my express permission. Exceptions:
Allergies & Allergic Reactions
Dietary Restrictions
Note: The parent or guardian must provide any special foods required by the child.
Special medical or psychological conditions of my child:
Physical Limitations:

Payment
prevnext( X )
Steubenville DepositOnline payments include a transaction fee
$77.02 Quantity



Steubenville Final Payment (after deposit)Online payments include a transaction fee
$128.04 Quantity



Steubenville Payment in fullOnline payments include a transaction fee
$204.56 Quantity



Total

$0.00
Should be Empty:

2025 Steubenville Mid America with OLS Life Teen

Medical Information