Boy’s Overnight Retreat Registration Form 2022 Please enable JavaScript in your browser to complete this form.1234STUDENT INFORMATION / INFORMACION DEL ESTUDIANTEStudent's Name /Nombre del estudiante *FirstMiddleLastCurrent Grade / Grado actualmente *7th8thAddress / Dirección *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone / Teléfono de casa *Student's Cell Phone / Celular del estudianteStudent's Email / Correo electrónico del estudiante *NextPARENT OR GUARDIAN INFORMATION / INFORMACION DEL PADRE O GUARDIANParent or Guardian Name /Nombre del Padre o Guardian *FirstLastParent or Guardian Email / Correo electrónico del Padre o Guardian *Parent or Guardian Cell Phone / Celular del Padre o Guardian *Parent or Guardian Work Phone / Teléfono del trabajo del Padre o GuardianRelationship to teen? / Cual es la relación con el estudiante?Mother / MadreFather/ PadreOther/ OtroPlease specify your relationship with the student/ Por favor especifique su relación con el estudiante *RELEASE FORMS / NOTA DE PERMISOSAFETY As the participant, I agree to follow all procedures, safety precautions, and rules and regulations set forth by the Diocese and the Parish.Print Full Name / Escriba su nombre completo *PARENTAL PERMISSION AND LIABILITY RELEASE As parent/legal guardian of the participant names above, I give my permission to participate fully in Confirmation Retreat at Hunting Ridge Retreat Center, 1011 Hunting Ridge Rd, Winchester, VA 22603 from October 15th at 7:30am until October 16th at 2:30pm . I agree to indemnify and hereby release the Most Reverend Michael F. Burbidge Bishop of the Catholic Diocese of Arlington and his successors in office, as well as the Catholic Diocese of Arlington and all Diocesan clergy, employees, volunteers, and participating parishes and schools from any and all liability, claims, demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned of the participant resulting from said participant’s involvement in the above mentioned event (including transportation to and from the event). Furthermore, I on behalf of the participant hereby assume all risk of personal injury, sickness, death, damage, and expenses resulting from said participant’s involvement in the above described event.Print Full Name/ Escriba su nombre completo *INFORMED CONSENT TO MEDICAL TREATMENT I request that in my absence the above-named minor be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor. I assume full responsibility for all costs of such treatment. Further, should it be necessary for the participant to return home due to medical, disciplinary, or other reasons, I do hereby assume responsibility for the participant’s transportation home and any costs related thereto.Print Full Name / Escriba su nombre completo *PHOTO, PRESS, AUDIO, AND ELECTRONIC MEDIA RELEASE I authorize the Catholic Diocese of Arlington, its parishes, its schools and/or the Arlington Catholic Herald to use and publish my child’s photograph, video and/or audio recording along with their name identifying them for educational, news stories, illustration and/or marketing purposes.Print Full Name/ Escriba su nombre completo *NextMEDICAL INFORMATION / INFORMACION MEDICA(ALL INFORMATION IS KEPT PRIVATE) / (TODA LA INFORMACION SE MANTIENE PRIVADA)Student Name/ Nombre del estudianteMEDICATIONS Please list any prescription or doctor prescribed over the counter medications your child is usingDrug Name/ Nombre del medicamentoDosage/ DosisDrug Name / Nombre del medicamentoDosage / DosisIn case there are additional drugs, please mention the drug name and its dosage below:/ En caso que haya medicina adicional, por favor mencionar el nombre del medicamento y su dosis abajo:ALLERGIESEnvironmental (i.e. pollen, dust) / Ambiental (Ej. polen, polvo)Any Medications/ Algún medicamentoFood/ ComidaDoes your child have an EPI-pen? / Su hijo usa un autoinyector de epinefrina?YesNoDo they know how to administer it to themselves? / Saben como autoadministrarlo el mismo?YesNoHISTORYMedical History (be specific) / Historial Médico (sea específico)Mental Health Information (be specific) / Infomacion de la Salud Mental (sea especifico)Physician and Medical InsurancePrimary Healthcare Provider/Proveedor primario del Cuidado de la saludPhone/ Numero de teléfonoInsurance Company/ Compañia de SeguroPolicy Number/ Número de pólizaEmergency ContactName/ Nombre *FirstLastRelationship / RelaciónPhone/ Número de teléfonoNextREGISTRATION FEE / COSTO DE LA REGISTRACIONThe fee for Winter Retreat covers the use of facilities, lodging, and food at Northbay Retreat Center. However, we will not and have never turned a youth away if cost is an issue. We would ask that you contribute what you can, if you need assistance, please do not hesitate to contact Katherine Aguilar, Director of Youth Ministry. If your student attends RCIT, please select the "No" option for payment. The cost for winter retreat is covered in the registration for RCIT. (Our online payment system is 100% safe and secure. We do NOT store any of your credit card information. We respect your privacy!)Credit Card? Other? (Make Payable to: St Leo the Great Youth Ministry) *Yes, I will pay via credit card. / Si, daré mi tarjeta de credito.No, I will pay cash. / No, daré cash.No, I will pay with check. / No, daré un cheque.TotalOne Student - $150Total$ 0.00Stripe Credit Card *CardName on CardBILLING DETAILS Our online payment system is 100% safe and secure. We do NOT store any of your credit card information. We respect your privacy!Submit