Christ the Redeemer Youth Ministry

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Welcome to the Teen Leader registration page for our Rise Retreat! We look forward to spending the weekend with you!

We will cover your expenses as our way of saying thank you! We couldn’t do this without you! The retreat takes place February 1-2, 2025 at Christ the Redeemer.

Qty

Description

Amount

Total

Encounter Confirmation I Retreat

$0.00

---

Covers food, supplies, and other costs

An additional 3.5% will be added to your fee to cover the processing costs.

Total: $0.00

Participant Information

Participant First Name: *

Participant Last Name: *

Gender: *

Date of Birth: *

dd/mm/yyyy

Teen Leader E-mail: *

TL Phone *

Home Address: *

City: *

Zip Code: *

Parent/Guardian: *

Phone: *

(xxx)xxx-xxxx
Best Phone to reach you.

Medical Information

Disabilities:

List disabilities and whether accommodations are needed. Feel free to contact us with more information.

My child is taking the following medication at the present time (leave blank if none):

Medication:

Dosage:

Administer:

I GRANT PERMISSION for prescription medication, provided by me, to be administered to my child as directed. My child will bring all such medications, well labeled, that are necessary. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency.

I grant permission for the following nonprescription medication to be given to my child if deemed advisable. I understand that Aspirin will not be given to my son/daughter.

Advil/Ibuprophen:

Antihistimine:

Antacid:

Decongestant:

Throat Lozenge:

Tylenol/Acet:

Medical Conditions
MY SON/DAUGHTER HAS

Leave blank if there are none. (Archdiocesan personnel will take reasonable care to see that the following information will be held in confidence)

Episode or Diagnosed:

Has had an episode or has been diagnosed with.

Allergic Reactions:

Other Allergies:

Medical surgery in last 6 mos:

Surgery Details:

Still Under Doctor Care:

Medically Prescribed Diet:

Physical Limitations:

Physical Limitations Details:

Immunizations Up To Date: *

Last Tetanus/Diphtheria Immunization:

(date)

Insurance Information

Do you carry medical insurance at this time: *

Insurance Carrier:

Name of Insured

Insurance Policy Number:

Father’s Name:

Day Phone:

(xxx)xxx-xxxx

Mother’s Name:

Day Phone:

(xxx)xxx-xxxx

Consent To Treat Minor:
I/we, the parent(s) or legal guardian(s) of the Participant, and as such do hereby authorize Christ the Redeemer Catholic Parish, its youth ministry leaders, employees, contractors and volunteers as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician or surgeon licensed under the laws of the jurisdiction where such diagnosis or treatment may be given, whether such diagnosis or treatment is rendered at the office of said physician, at a hospital, or at any other location. It is understood that this authorization is given in advance of any specific treatment or diagnosis, but is given to provide authority and power of treatment, or hospital care which the aforementioned physician in the exercise of best judgment may deem advisable. This authorization is given pursuant to the provisions of Chapter 32 of the Texas Family Code. This authorization shall remain effective for up to one year from the date of completion of this form, unless sooner revoked in writing delivered to said agent(s). In consideration of acceptance of this authorization, but without any time limitation and without any future right of revocation, I/we hereby release, defend and hold harmless the Parish and Roman Catholic Archdiocese of Galveston-Houston (Diocese), their officers, directors, agents, employees, volunteers, youth ministry leaders, and contractors from all claims, liabilities and loss in any way arising out of or in connection with or relating to such treatment and treatment decisions.

I have read this consent for medical treatment of a minor statement, and I understand and voluntarily agree to its provisions.

CONSENT TO PARTICIPATE AND LIABILITY RELEASE:
I am the parent or legal guardian of the above Participant, who is under 18 years of age and will participate in the Youth Group Fall Retreat. I am fully competent to sign this Agreement, and I grant permission for my son/daughter to participate in all youth activities and functions. I understand that as parent/guardian/conservator, I remain legally responsible for any personal actions taken by my son/daughter. I recognize the inherent risk associated with the various youth activities that my son/daughter will be participating in. I agree on behalf of myself, my son/daughter named herein, my heirs, successors, and assigns to indemnify, defend, and hold harmless Christ the Redeemer Catholic Parish and the Roman Catholic Archdiocese of Galveston-Houston, their employees and/or volunteers from any and all claims (unless due to the Sole or Gross NEGLIGENCE of the Parish) for illness, injury, death, and the cost of medical treatment therewith, arising from or in any way connected with my son/daughter participating and/or attending the various youth programs and activities during this formation year noted above. In the event any legal action is taken by either party against the other party to enforce any of the terms and conditions of this release, it is agreed that the unsuccessful party to such action shall pay to the prevailing party therein all reasonable court costs, reasonable attorneys’ fees and expenses incurred by the prevailing party.

I have read this release statement, and I understand and voluntarily agree to its provisions.

Audio/Visual Recording and Photography Consent:
On occasion, video recordings, audio recordings, photographic slides, and photographs are taken of children and youth during church and diocesan sponsored activities. These are utilized in newsletters, websites, event promotion, advertisements and other printed media. As the State of Texas does not prevent audio or video recording or the photographing of children/youth (with the exception of Senate Bill 1, Section 26.009, which deals specifically with school districts), it does encourage parental consent. Additionally, current video recordings and photographs assist law enforcement agencies dealing with the Missing Children’s Program. I release the staff and volunteers of Christ the Redeemer Catholic Parish and the Roman Catholic Archdiocese of Galveston-Houston from any liability connected with the use of my child’s picture or audio/video recording as part of any of the above or similar activities.

Media Release: *

Payer Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *