Men's Discernment Retreat: Parental Consent for Minors Form

Parental Consent Form for Minors

Please complete this form to provide consent for your minor child.
Men's Discernment Retreat: "Come Follow Me"

Friday, December 18, 2026 through Sunday, December 20, 2026 • Loyola Retreat House - 700 Killinger Rd, Clinton, OH 44216
Event Time

5:00 PM Friday through 2:00 PM Sunday
Event Time: 5:00 PM Friday through 2:00 PM Sunday
Child's Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Child's Email Address
example@example.com
Parish Affiliation/Organization Name
Parent/Guardian Full Name

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Parent/Guardian Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Additional Emergency Contact Full Name

First NameLast Name
Additional Emergency Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Conditions or Allergies
My son is taking medications at present. He will bring all necessary medications and such medications will be well labeled. The names of and the concise directions for taking such medications, including dosage and frequency of dosage as follows.
Current Medications
Additional Medical Information
Medication Permission
Family Doctor
Family Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Hospital and Location
Is the hospital allowed to treat your child?
Emergency Instructions or Notes
Include anything staff should know right away.
What insurance is the child covered under?
Policy number
I do not want any medical treatment to be given to my son under any circumstances. I hereby assume all responsibility for the health and well being of my son and release from responsibility the Bishop of the Diocese of Youngstown, and the parish/school, and the agents, associates, and employees of the Bishop and parish who have organized or participated in the supervision of such program.
Agreement Section
Youth Agreement:

I understand that my participation in this program requires compliance with specific regulations for this event. I agree to abide by all rules and regulations set forth. Any infraction of the rules or regulations, including, but not limited to, the possession of alcohol, drugs, or weapons will result in dismissal from the program. If I should be dismissed, I understand that my parents will be contacted to arrange for my immediate transportation home.
Youth Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I grant permission for my son to participate in the Come Follow me: Men’s discernment retreat at (Loyola Retreat House) on (Dec.18th through Dec. 20th) who is less than nineteen years of age.

By allowing my child to participate in the Men's Discernment Retreat program, I hereby assume all risk of accident or harm arising or growing out of, directly or indirectly, any incident of any kind occurring during the course of such program to my child and do hereby release and discharge the Bishop of the Diocese of Youngstown, and my parish/school/organization, and the agents, associates, and employees of the Bishop and parish/school who have organized or participated in the supervision of such program from all claims, demands, suits, causes or actions, rights, costs, expenses, and any compensations whatsoever which may occur to my family and its members during or resulting from participating in the program mentioned.

I am aware of the particulars of the Men's Discernment Retreat program including the times, costs, and adults chaperoning and transporting my child for the program and have clarified any concerns I may have with the coordinating adult in charge. I agree that my son/daughter shall abide by the rules and all regulations of the program including in possession of alcoholic beverages, drugs, and weapons. I agree that if my son/daughter fails to abide by the regulations set forth, he/she will be dismissed from the program and I will need to arrange for his/her immediate transportation home at my expense

I understand that the Men’s Discernment Retreat is an overnight retreat and my son will be staying Friday-Sunday.
Parental Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Communication Consent

Please indicate how the child may be contacted.
I authorize communication via:

Other
Cell number(s)
Please enter a valid phone number.Format: (000) 000-0000.
Facebook (or other Social networking) name(s)
Email address(es)
example@example.com
Photo Release Consent

Please review and sign below to grant photo use permission.
I give permission for photos and videos taken during this event to be used for parish, school, or organization purposes, including newsletters, websites, and social media.

I understand this consent is voluntary and may be revoked only by contacting the event organizer.
Parent/Guardian Photo Release Signature
Wheelchair Access/Mobility Impaired Blind/Visually Impaired Hearing Impaired/Interpretation Needed Interpretation Not Needed Please note: All areas utilized are not ADA accessible. Contact (Your Parish) if special arrangements need to be made.
Should be Empty:

Parental Consent Form for Minors

Men's Discernment Retreat: "Come Follow Me"

Event Time

Agreement Section

Communication Consent

Photo Release Consent