Love's Reply Retreat - Archdiocese of Kansas City in Kansas

Love's Reply Permission & Liability Waiver for Minors

ARCHKCK, Permission & Liability Waiver

General Information

Retreatant's First and Last Name(Required)

Date of Birth(Required)

Parent(s) Name(s)(Required)

Parent(s) Phone(Required)

Parent(s) email address(Required)

Emergency Contact Name and Phone(Required)

Health Information

Is this participant in general good health and able to participate in general activities (if not, please explain).(Required)

Name of retreatant's physician(Required)

Physician's phone number(Required)

Is your daughter presently taking any medications?(Required)

yes

If yes, please list them and provide directions for frequency and dosage.

Will your daughter be bringing any over the counter medications with her?(Required)

yes

If so, please list them:

Please list any special dietary needs or allergies:

Health Insurance Company(Required)

Health Insurance Policy #(Required)

Name of Primary Health Insurance Holder(Required)

Permissions and Liability

Participants will spend their time at Prairie Star Ranch under the supervision of designated chaperones. The planned activities include but may not be limited to: Adoration, Mass, confession, board games, prayer, meals and discussions.

Please check all that apply:(Required)

I hereby certify that the above information is correct and give permission for the release of medical records to an attending physician in case of illness. In case of medical emergency, I understand that every effort will be made to contact parent(s) or guardian(s) of participants. In the event that I cannot be reached, I hereby give permission to the physician selected by the Archdiocese to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for my child, as named herein.

I request that my daughter be allowed to participate in the Love's Reply Discernment Retreat at Prairie Star Ranch, I hereby release and indemnify the Archdiocese of Kansas City in Kansas, its staff, and volunteers from any liability arising from claims of any kind or nature whatsoever from my daughter's participation in this program.

My daughter may be given over the counter medication (such as Tylenol, Tums, Advil, cough drops).

During the retreat, I give my permission to the Archdiocese of Kansas City in Kansas to take photographs and video of my child to possibly be used for future promotional use.

Parent's Electronic Signature

Today's Date

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Name

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Love’s Reply Retreat

Love's Reply Permission & Liability Waiver for Minors

General Information

Health Information

Permissions and Liability

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