LIFE TEEN RETREAT Registration Form Please turn in your forms by February 22 in order to receive the discounted price and be guaranteed a T-shirt Get yours in early! Don t be shut out! The first 4 pages of this application must be filled out completely and turned in with payment. WHEN: Friday, March 4th to Sunday, March 6th, 2016 WHERE: TIME: Hiram House Camp: Chagrin Falls, OH (bus transportation provided to & from camp) Camp phone: 216-831-5045 Tommy s cell phone: 440-478-5802 Friday: Meet at St. Basil Parish Center PROMPTLY@ 6:00 pm Dinner will not be served. Please eat before you arrive! Sunday: Return from camp for the 5:30 pm Mass at St. Basil Parents are welcome and encouraged to join us for Mass COST: $95 (applications received by Monday, February 22th) $110 (applications received after Monday February 22th) Checks payable to St. Basil the Great Teen s Name Cell Phone: (first and last - exactly as you want it printed on your nametag) Home Phone: School: Grade: Male / Female (circle one) Vegetarian: Y or N Parent Email Address: Please list the names of 3 people you would room with at camp. T-shirt size: Adult Sizes: (Please circle requested size) S M L XL XXL (shirt only guaranteed if you are registered by February 22th) 1 of 5
MEDICAL RELEASE FORM & PARENT CONSENT FORM: Teen s name Birth Date / / (Last) (First) (MI) Address (Street) (City) (State) (Zip Code) Parent/Guardian Name Daytime Phone ( )_ Evening Phone ( )_ Cell Phone ( )_ Address of Guardian (if address is different than above) (Street) (City) (State) (Zip Code) Alternate contact- In case of emergency and parents can not be reached, we should contact: Name Daytime Phone ( ) Evening Phone ( ) Cell Phone ( ) Medication(s) teen can NOT take Please list any allergies, and/or medications taken on a regular basis. In addition, please specify information that your teen s Adult Table Leader should be aware of- including specific medical problems your teen may have: 2 of 5
INSURANCE INFO IS REQUIRED TO ATTEND THE RETREAT Insurance Co. Phone ( ) Policy # Group # Policy Holder s Identification # Name of Policy Holder Policy Holder s Employer Doctor s Name Phone ( ) Dentist s Name Phone ( ) Medical Release & Parent Consent Form I/we the parent (s) or legal guardian (s) of _ do hereby give my consent for Tommy Dome or other official adult representative of the St. Basil youth program, in the event that all reasonable attempts to contact me at the numbers provided have been unsuccessful, to seek medical attention and treatment as deemed necessary. This authorization does not cover major surgery unless the medical opinion of two other licensed physicians or dentists concur in the necessity for such surgery and are obtained before surgery is performed. Further, and unless specified otherwise, consent/permission is hereby given to Tommy Dome, and all accompanying adult chaperone leaders on this trip to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery (under recommendation of qualified medical personnel). I agree that my insurance company will be used for such medical care expenses and I am aware that I may be billed by the medical provider for any medical treatment expenses not covered by my insurance. I understand that if I do not have medical insurance coverage that I am responsible for the payment of any medical bills. Any and all information concerning the above named child s history including allergies, medications and physical impairments, has been reported in these registration forms. In the event of an emergency, I authorize the St. Basil youth program to share the completed registration information packet with persons related to the treatment of the above named program member. I agree to all of the above statements, and that they are accurate and true. Parents/Guardians Signature Witnessed by Date 3 of 5
TEEN STATEMENT OF RESPONSIBILITY: I request to participate in the St. Basil Life Teen Retreat. I understand that by requesting to go, I am promising to cooperate with the retreat team, the Life Teen Staff, and the Holy Spirit. I understand that the intention of the retreat is to help form community and to bring me closer to God. I promise to follow instructions and be open. I also realize that I may not bring or use any tobacco products, illegal drugs or alcohol. I understand that pop, cell phones, ipods or any electrical equipment whatsoever, are NOT permitted. I have read and will comply with the To Bring/Not to Bring List. I understand that to break the retreat rules or to act unsafely or irresponsibly will result in my dismissal from the camp into my parents care. (Teen Signature) PARENT STATEMENT OF RESPONSIBILITY: My son/daughter has my permission to attend St. Basil Life Teen retreat to be held at Hiram House Camp, in Chagrin Falls, OH. Life Teen Core Members will serve as adult chaperones for the trip. Teens will be transported by bus to and from the retreat. No students are allowed to drive to the retreat. Participants are required to stay the entire time. I support the right of the group s leaders to have me come & pick up my teen at any time if given just cause. I understand that my teen is not permitted to bring pop, a cell phone, ipod, or any electrical equipment whatsoever. I have read and understand the To Bring/Not to Bring list. The undersigned hereby gives approval for my child to participate and does waive, release, save and hold harmless and indemnify St. Basil the Great, Life Teen Core Members, organizers and agents from any personal injury to my child. (Signature of Parent/Guardian) PHOTO RELEASE FORM: As a participant in the Life Teen program, I hereby give St. Basil Church, and the Life Teen program my permission to use my likeness in photo or video form and my name in publicity, both within internal communication of the above-mentioned groups for use in communication pieces, and to area news media in all forms without limit as to time. I further release them from liability for what I might deem a misrepresentation of me by virtue of alterations, optical illusions, or faulty mechanical reproduction. (Signature of Parent/Guardian) (Teen Signature if 18-years-old at date of retreat) 4 of 5
Life Teen Retreat Information Sheet (DO NOT TURN IN) DATE/TIMES: March 4 th to March 6 th (Friday to Sunday), 2016 Friday: Meet at St. Basil Parish Center PROMPTLY at 6:00 pm Dinner will not be served. Please eat before you arrive! (Pizza is provided later in evening) Sunday: Return from camp for the 5:30 pm Mass at St. Basil (Parents are welcome and encouraged to join us for Mass) CAMP/CONTACT INFORMATION Hiram House Camp 33775 Hiram Trail, Chagrin Falls OH 44022, (Camp phone): 216-831-5045 Tommy Dome s cell phone: 440-478-5802 *Teens will be sleeping in modern cabins on bunk-style beds. Go to Hiramhousecamp.org for detailed information and pictures of the camp and cabins.* WHAT TO BRING old, warm, comfortable clothing (layer according to weather) Please no yoga pants or leggings worn as pants outside of the girls cabins. weather appropriate outerwear refillable sports WATER BOTTLE old shoes (at least two pairs boots recommended) several pairs of socks toiletries (soap, shampoo and deodorant) washcloth & towels sleeping bag pillow sweats to sleep in outdoor sports equipment frisbee, footballs, cards, Nerf stuff rain poncho (optional) Rosary open heart -- required open mind also required WHAT NOT TO BRING No yoga pants or leggings worn as pants are allowed outside of the girls cabin. Absolutely no pop, Gatorade, or juice allowed in the cabins, per Hiram House camp rules NO cell phones!!!! NO ipods NO electrical devices whatsoever NO valuables (anything you wouldn t want to lose) NO alcohol or tobacco products NO illegal drugs NO bad attitudes or closed minds 5 of 5