Winter Retreat Register for Winter Retreat Please enable JavaScript in your browser to complete this form.1234STUDENT INFORMATIONStudent's Name *FirstMiddleLastCurrent Grade *9th10th11th12thAddress *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 *9th10th11th12thAdd third students information? *YesNoStudent Name *FirstMiddleLastStudent's Email *Current Grade *9th10th11th12thNextPARENT/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.Signature *Clear SignaturePrint Full Name *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 St. Mary of Sorrows (5222 Sideburn Rd, Fairfax, VA 22032) from February 26th (5:30pm to 9:00pm), February 27th (10:00am to 8:30pm), to February 28th (9:00am to 1:00pm), 2021. 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.Signature *Clear SignaturePrint 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.Signature *Clear SignaturePrint 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.Signature *Clear SignaturePrint 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 *FirstLastRelationshipPhoneNextREGISTRATION FEEAs a reminder, in an effort to offset the cost of snacks, meals, youth ministry t-shirt and materials for youth events during the year, St. Leo’s does assess an Activity Fee. 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 Melissa Rhil, Director of Youth Ministry. The activity fee structure also takes into account family with multiple participating children: Middle School: $60/youth High School: $85/youth Family (two or more students): $120/family (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? *Yes, I'll pay right now!No, I'll give you a check. (Please choose if you need to defer payment at this time)TotalOne Student - $15Two Students - $30Three Students - $45Four Students - $60BILLING 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 CardNumbersSubmit