Sign up to go with Christ the Redeemer Youth Ministry to the Steubenville Mid-America High School Youth Conference “Belong” Summer 2019! This summer over 40, 000 High School teens will gather at a Steubenville Youth Conference to pray, praise, and adore God. They will see dynamic speakers, experience excellent praise and worship, and encounter God in a profound way. We will spend the next several months praying, fundraising and preparing! Steubenville Mid-America is July 21-14, 2019 at Missouri State University in Springfield, MO.

Steubenville High School Youth Conference 2018 “Belong”. $50.00 deposit. The deposit reserves your spot and is non-refundable. The rest of the payments can be fundraised and are due at a later time.

Qty
Description
Amount
Total

$50.00
$50.00
Total: $50.00
Future Commitment: $0.00
Participant Information
dd/mm/yyyy
(xxx)xxx-xxxx
Best phone to reach you.
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 Steubenville High School Youth Conference. 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.
I have read this consent for Media Release, and I understand and voluntarily agree to its provisions.
Medical Information
(xxx)xxx-xxxx
(please include area code)
Challenges, Concerns, Medication, Allergies: (learning challenges, social concerns, medications and/or allergies)
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 are as follows:
My child is taking the following medication at the present time:
I hereby DO NOT GRANT PERMISSION for medication of any type, whether prescription or nonprescription may be administered to my child unless the situation is life threatening and emergency treatment is required
I hereby GRANT PERMISSION for nonprescription medication to be given to my child if deemed advisable. I understand that Aspirin will not be given to my son/daughter.
I grant permission for the following nonprescription medication to be given to my child.
Medical Conditions Information: (Archdiocesan personnel will take reasonable care to see that the following information will be held in confidence)
My son/daughter has
Has had an episode or has been diagnosed with.
(date)
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.
Insurance Information
(xxx)xxx-xxxx
(xxx)xxx-xxxx
Payer Information
This is the address where your credit card statements are mailed.
(xxx)xxx-xxxx
A receipt will be e-mailed to this address.
Your Payment Information

VisaMasterCardDiscoverJCB

Powered by Acceptiva