YG Day Trip Registration

Thank you for your interest in our day trip to the

National Shrine of St. Maximilian Kolbe, in Libertyville, IL.

Our visit will include a guided tour of the Holocaust Exhibit and video on St. Kolbe, noon Mass, and time to visit the outdoor Rosary Walk, Shrines and gift shop.

This is for youth going into 6th grade through outgoing 12th graders.

Tuesday, August 5th, 2025. 8:30am-5:00pm

For this trip we will join the Youth Group from St.Gall in Elburn.

Our bus will depart from St.Gall and return there.

They are located at 43w885 Hughes Rd, Elburn, IL 60119

Parents are responsible for transportation to and from St.Gall.

Please arrive to St.Gall by 8:30am on Aug 5th, and youth should be picked up at 5pm.

Cost is $30, and please carry a sack lunch.

For questions please email Veronica & Gabi at youthminister@newmanniu.org.

Family Information:

This will be our MAIN point of contact. Please be sure we have a current email address and telephone/cell phone number for communications.

Parent Name*

First NameLast Name

Address

Street Address Line 1

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number*

Email*

Spouse Name

First NameLast Name

Cell Phone Number

Email

Emergency Contact:

Please indicate someone other than parent/guardian listed above. The emergency contact will be used in the case when we cannot reach the parent/guardian.

Name*

First NameLast Name

Relationship to Students*

Cell Phone Number*

Student Information:

Complete form for each child you'd like to register.

STUDENT #1

Please list any learning considerations, special needs or medical concerns for your student listed above

STUDENT #2

Please list any learning considerations, special needs or medical concerns for your student listed above

STUDENT #3

Please list any learning considerations, special needs or medical concerns for your student listed above

STUDENT #4

Please list any learning considerations, special needs or medical concerns for your student listed above

Permissions:

I am the parent or legal guardian of the child(ren) indicated above*

YesNo

Consent: I grant my permission for my child listed above to participate in the above listed CHURCH SPONSORED ACTIVITY to attend on August 5, 2025*

YesNo

Student Cooperation: My child agrees to abide by all the rules of aforementioned Activity and to obey the staff in charge of this Activity. The Parish, School, and Diocese will not be liable for my child's failure to cooperate and/or to abide by the rules. Any infraction of the rules may result in the immediate dismissal of my child from the Activity at my expense and without refund to me of the costs paid for the Activity.*

YesNo

First-Aid/Emergency Treatment: I authorize Christ the Teacher/Newman Center employees and volunteers to administer first-aid to my child if deemed necessary and appropriate to preserve the life, limb or well-being of my child. I authorize the Parish to contact and engage medical personnel arrange for emergency treatment of my child, including transportation for medical, dental, surgical or hospital care or diagnosis, and I consent to that treatment for my child. I agree that I am financially responsible for such medical treatment.*

YesNo

Release: I hereby release and discharge The Diocese of Rockford and its Bishop, and the Parish and School, and the officers, directors, employees, and volunteers of same, from all claims for personal injuries or property damage that I or my child may suffer while my child is attending and/or participating in the Activity, unless the injuries or damage resulted from willful misconduct of the Diocese, the Parish, the School or its employees. If I have provided medication for my child to take during this Activity, I hereby release and discharge The Diocese of Rockford and its Bishop, and the Parish and School, and the officers, directors, employees, and volunteers of same, from all claims for personal injuries or property damage that I or my child may suffer as a result of the administration of or lack of administration of or assistance in or lack of assistance in the administration of said medication to my child, whether by my child and/or an adult employee and/or an adult volunteer; unless the injuries or damage resulted from willful misconduct of the Diocese, the Parish, the School or its employees.*

YesNo

Media Release: By registering your child(ren) you grant the Parish and/or Diocese of Rockford permission to use your child's image and likeness in photographs and to be published on our website, in our bulletin, and in our local/diocesan newspaper including their name. If you do not grant permission, you must submit a written letter stating otherwise. I have read this statement.

Yes

Name of Person Submitting Form*

Signature*