Antioch Retreat Consent Form and Liability Waiver Due June 25After a successful submission, you will receive a message at the top of the page, thanking you for submitting. If the form didn't clear after you clicked submit, an error occurred. Scroll to the top of the page to see what errors occurred. Thanks!Dates: January 12-14, 2024 Location: Cherokee Retreat Center Individual in Charge: Theresa Brader, 770-977-1442, ext. 161 Return: Transfiguration to attend 5 p.m. Mass on Sunday Transportation to and from event: Parents Cost: Included in Confirmation Preparation Emergency Cell Phone: Theresa, 919-632-7151, Karen, 770-289-0480Participant InformationTeen's Name* First Last Name Nickname Gender* Male Female T-Shirt Size*SmallMediumLargeExtra LargeXX Large3X LargeTeen's Email Enter Email Confirm Email High School Attending in 2023-2024* Parent/Guardian InformationParent/Guardian Name* First Last Parent/Guardian Email* Enter Email Confirm Email Parent Cell Phone Number*Emergency/Medical InformationCell Phone Number Where Parent can be Reached during Retreat.*Alternate Emergency Contact Person (if parent can not be reached).* First Last Alternate Person Relationship to Participant.* Alternate Emergency Contact Cell Phone Number.*Please note any special medical issues, allergies, food restrictions, or limitations that the chaperones will need to be aware of.I Grant Permission to Give Over the Counter Medication if Deemed Appropriate.* Yes No Volunteer InformationCan You be a Volunteer Driver?* Yes No Have you completed the SAFE Environment training? Yes No Availability Friday Sunday Either day I am a superhero and can do both days How Many Available Seats does your Vehicle Have (do not include driver)?12345678Teen Code of ConductIn submitting this form, I agree to abide by all policies and rules established for this event. Should I not be able to maintain the guidelines and expectations of the adults and my peers, I understand that there will be consequences for my actions, including being removed from the event and being sent home at my parent's expense. Basic rules/expectations include, but are not limited to, the following: Respect for all adult leaders, peers, and all property; No illegal drugs, alcohol, underage smoking, firearms, explosives, weapons or other illegal substances; Males and females are to remain in separate sleeping spaces at all times; No inappropriate physical/sexual activity; Appropriate attire to be worn at all times. Other guidelines may be set forth accordingly by adult chaperones present for the event.Participant Acknowledgement* I Agree Parent ReleaseI (Parent/Guardian above) grant permission for my child (Participant Above) to participate in this parish youth ministry event that requires transportation to a location away from the parish site. This activity will take place under the guidance and direction of parish employees and/or volunteer from the parish. A brief description of the activity is given above. As parent and/or legal guardian, I remain legally responsible for any personal actions taken by my child. I agree on behalf on myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend Transfiguration Catholic Church, its officers, directors and agents, and the Archdiocese of Atlanta, Georgia, chaperons, or representatives associated with the event, arising from or in connection with my child attending the event or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors and agents, and the Archdiocese of Atlanta, chaperons, or representative associated with the event for reasonable attorney's fees and expenses arising in connection therewith.Parent Acknowledgement* I agree to the Parent Release and by submitting this form, I am electronically signing this document. Parent's Electronic Signature* Date of Acknowledgement* MM slash DD slash YYYY Time* : Hours Minutes AM PM AM/PM Would you like an E-mail copy of the submission?* Yes No CommentsThis field is for validation purposes and should be left unchanged.
