Winter Retreat Packet 2023 Please enable JavaScript in your browser to complete this form.1234STUDENT INFORMATIONStudent's Name ( Nombre del estudiante) *FirstMiddleLastCurrent Grade ( Grado actual) *9th10th11th12thAddress (Direccion) *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone (Telefono de casa) *Student's Cell Phone ( Celular del estudiante)Student's Email (Correo electronico del estudiante) *Add second students information? (Agrega la informacion de un segundo estudiante?) *YesNoStudent Name (Nombre del estudiante) *FirstMiddleLastStudent's Email (Correo electronico del estudiante) *Current Grade (Grado actual) *9th10th11th12thAdd third students information? ( Agrega un tercer estudiante? *YesNoStudent Name (Nombre del estudiante) *FirstMiddleLastStudent's Email ( Correo electronico del estudiante) *Current Grade (Grado actual) *9th10th11th12thNextPARENT/GUARDIAN INFORMATION (INFORMACION DEL PADRE/GUARDIAN)Parent/Guardian Name (Nombre del Padre/Guardian) *FirstLastParent/Guardian Email ( Correo electronico del Padre/Guardian) *Parent/Guardian Cell Phone ( Numero de telefono del Padre/Guardian) *Parent/Guardian Work Phone (Numero de telefono del Padre/Guardian)Relationship to teen? ( Relacion con el estudiante)Mother (Madre)Father (Padre)Other (Otro)Please specify your relationship with the student/teen (Por favor especifique su relacion con el estudiante/joven) *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 ( Escriba su nombre) *PARENTAL PERMISSION AND LIABILITY RELEASE As parent/legal guardian of the participant names above, I give my permission to participate fully in Winter Retreat at Northbay (11 Horseshoe Point Ln, North East, MD 21901) from February 10th at 4:00pm until February 12th 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) *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) *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) *NextMEDICAL INFORMATION (INFORMACION MEDICA)(ALL INFORMATION IS KEPT PRIVATE) ( TODA LA INFORMACION ES PRIVADA)Student Name (Nombre del estudiante)MEDICATIONS Please list any prescription or doctor prescribed over the counter medications your child is usingDrug Name (Nombre de la medicina)Dosage (Dosis)Drug Name (Nombre de la medicina)Dosage (Dosis)In case there are additional drugs, please mention the drug name and its dosage below: ( En caso de medicina adicional, por favor mencione el nombre de la medicina y su dosis abajo:)ALLERGIESEnvironmental (i.e. pollen, dust) (Ambiental e.g polen, polvo)Any Medications (Algunas medicaciones)Food (Comida)Does your child have an EPI-pen? ( Su hijo usa un lapiz autoinyector)YesNoDo they know how to administer it to themselves? (Ellos saben como administrarlo ellos mismos)Yes (Si)No (No)HISTORYMedical History (be specific) ( Historial Medico, sea especifico)Mental Health Information (be specific) (Informacion de Salud mental, sea especifico)Are you registering a second student? (Esta registrando un segundo estudiante?)Yes (Si)NoSecond Student's Name ( Nombre del segundo estudiante)MEDICATIONS Please list any prescription or doctor prescribed over the counter medications your child is usingDrug Name (Nombre de la medicina)Dosage (Dosis)Drug Name (Nombre de la medicina)Dosage (Dosis)In case there are additional drugs, please mention the drug name and its dosage below: ( En caso que haya medicina adicional, por favor mencione el nombre y la dosis de la medicina abajo:)ALLERGIESEnvironmental (i.e. pollen, dust) ( Ambiental e.g polen, polvo)Any Medications (Algunas medicaciones)Food (Comida)Does your child have an EPI-pen? (Tiene un lapiz autoinyector)YesNoDo they know how to administer it to themselves? (Sabe como auto administrarlo)YesNoHISTORYSecond Student's Medical History (be specific) ( Historial medico del segundo estudiante, sea especifico)Second Student's Mental Health Information (be specific) ( Informacion de la salud mental del segundo estudiante, sea especifico)Are you registering a third student? ( Registra a un tercer estudiante?)Yes (Si)NoThird Student's Name (Nombre del tercer estudiante)MEDICATIONS Please list any prescription or doctor prescribed over the counter medications your child is usingDrug Name (Nombre de la medicina)Dosage (Dosis)Drug Name (Nombre de la medicina)Dosage (Dosis)In case there are additional drugs, please mention the drug name and its dosage below: ( En caso de medicina adicional, por favor menciones el nombre y la dosis de la medicina abajo:)ALLERGIESEnvironmental (i.e. pollen, dust) (Ambiente e.g polen, polvo)Any Medications (Algunas medicaciones)Food (Comida)Does your child have an EPI-pen? (Su hijo tiene un lapiz autoinyector?)YesNoDo they know how to administer it to themselves? ( Sabe como autoadministrarlo)YesNoHISTORYThird Student's Medical History (be specific) )( Historial medico del tercer estudiante)Third Student's Mental Health Information (be specific) ( Informacion de la salud mental del tercer estudiante)Physician and Medical InsurancePrimary Healthcare Provider (Proveedor de Salud Primario)Phone (Telefono)Insurance Company (Compañia medica)Policy Number (Numero de poliza)Emergency ContactName (Nombre) *FirstLastRelationship (Relacion)Phone ( Telefono)NextREGISTRATION FEE ( Costo de registracion)The 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 OCIT, please select the "No" option for payment. The cost for winter retreat is covered in the registration for OCIT. (Our online payment system is 100% safe and secure. We do NOT store any of your credit card information. We respect your privacy!)Would you like to save time & pay the registration fee online right now? ( Le gustaria ahorrar tiempo y pagar en linea ahora mismo?) *I'm an OCIT student (Soy estudiente de OCIT)Yes, I'll pay right now! ( Si, pagaré ahora mismo)No, I'll give you a check. (Please choose if you would like to defer payment at this time) ( No, daré un cheque. Por favor escoja si quiere atrasar el pago)Defer payment at this time (Atrasar el pago)TotalOne Student - $180Two Students - $270Three Students - $360BILLING DETAILS 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 *CardName on CardSubmit