Please enable JavaScript in your browser to complete this form.123STUDENT INFORMATIONStudent's Name *FirstMiddleLastCurrent Grade *9th10th11th12thT-Shirt SizeAdult-SmallAdult-MediumAdult-LargeAdult-XLargeAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone *Student's Cell PhoneStudent's Email *Add second students information? *YesNoStudent Name *FirstMiddleLastStudent's Email *Current Grade *9th10th11th12thT-Shirt SizeAdult-SmallAdult-MediumAdult-LargeAdult-XLargeAdd third students information? *YesNoStudent Name *FirstMiddleLastStudent's Email *Current Grade *9th10th11th12thT-Shirt SizeAdult-SmallAdult-MediumAdult-LargeAdult-XLargeNextPARENT/GUARDIAN INFORMATIONParent/Guardian Name *FirstLastParent/Guardian Email *Parent/Guardian Cell Phone *Parent/Guardian Work PhoneRelationship to teen?MotherFatherOtherPlease specify your relationship with the student/teen *RELEASE FORMSSAFETY *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 *PARENTAL PERMISSION AND LIABILITY RELEASE *As parent/legal guardian of the participant names above, I give my permission to participate fully in St. Leo’s Confirmation Retreat at St. Leo the Great Catholic Church & School October 2, 2021 from 8:00am to 4:30pm. 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 *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 *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 *NextMEDICAL INFORMATION(ALL INFORMATION IS KEPT PRIVATE)Student NameMEDICATIONS Please list any prescription or doctor prescribed over the counter medications your child is usingDrug NameDosageDrug NameDosageIn case there are additional drugs, please mention the drug name and its dosage below:ALLERGIESEnvironmental (i.e. pollen, dust)Any MedicationsFoodDoes your child have an EPI-pen?YesNoDo they know how to administer it to themselves?YesNoHISTORYMedical History (be specific)Mental Health Information (be specific)Are you registering a second student?YesNoSecond Student's NameMEDICATIONS Please list any prescription or doctor prescribed over the counter medications your child is usingDrug NameDosage Drug NameDosageIn case there are additional drugs, please mention the drug name and its dosage below:ALLERGIESEnvironmental (i.e. pollen, dust)Any MedicationsFoodDoes your child have an EPI-pen? YesNoDo they know how to administer it to themselves?YesNoHISTORYSecond Student's Medical History (be specific) Second Student's Mental Health Information (be specific)Are you registering a third student?YesNoThird Student's NameMEDICATIONS Please list any prescription or doctor prescribed over the counter medications your child is usingDrug NameDosageDrug NameDosageIn case there are additional drugs, please mention the drug name and its dosage below:ALLERGIESEnvironmental (i.e. pollen, dust)Any MedicationsFood Does your child have an EPI-pen?YesNoDo they know how to administer it to themselves?YesNoHISTORYThird Student's Medical History (be specific)Third Student's Mental Health Information (be specific)Physician and Medical InsurancePrimary Healthcare ProviderPhoneInsurance CompanyPolicy NumberEmergency ContactName *FirstLastRelationshipPhoneSubmit