* 1. This registration form is for Redeo Six, St. Joseph's Youth Ministry Semester retreat. This event begins on October 13, 2017 at 6:30pm and ends on October 15, 2017 at 6pm. Transportation will be by school bus to Camp Crystal Lake in Starke, FL. The Cost for this event is $100 per teen. 

* 2. Name of Child

* 3. Date of Birth


* 4. Home Address

* 5. Parent/Guardian 1 Name & Contact Information

* 6. T-Shirt Size

* 7. The above child is eligible to participate in the above parish-sponsored event requiring transportation to a location away from the parish grounds. This activity will take place under the guidance and supervision of employees/volunteers from the above parish. If you would like your child to participate in this event, please read, complete, and electronically sign and submit this form which includes your consent, as well as a full release of liability. As a parent or legal guardian, you remain fully responsible for any acts of the named child during this activity. 

* 8. Please list any known allergies

* 9. Physician's Name/ Telephone Number 

* 10. The undersigned parent, guardian or legal representative hereby consents to the participation of the above-noted child in the event described and further consents to the conditions state above on participating in this event, including the method of transportation. It is understood that this event will take place away from the parish grounds and that the child will be under the supervision of a designated parish employee/volunteers on the stated dates. 

For and in consideration of the child being allowed to participate in this event, and other valuable consideration, the undersigned parent, guardian or legal representative, on behalf of the child and the child's parents, personal representatives, assigns, heirs, and next of kin, does hereby release and hold harmless the Diocese of St. Augustine, Bishop Felipe J. Estevez, S.T.D, as Bishop of the Diocese of St. Augustine, a corporation sole, Bishop Felipe J. Estevez, S.T.D., individually, the above-noted parish, and employees and agents of said parties engaged in this particular event, their personal representatives or assigns, from any loss of damage on account of any injury to the person or the personal property, of the child, or death, caused by negligence or otherwise, while the child is engaged in the above-stated event or in transportation to and from said event. The undersigned expressly agrees that this release, waiver and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the State of Florida, and that if any portion of this Agreement is held invalid, it is agreed that the balance shall, not withstanding, continue in full legal force and effect. 

The undersigned parent, legal representative further acknowledges that he/she is authorized to enter this Agreement on behalf of the child, and the child's parents, personal representatives, assigns, heirs, and next of kin.

* 11. MEDICAL MATTERS: I do hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. 

EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I hereby give permission to the Diocese of St. Augustine's employees, volunteers to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child above named. 

* 12. In the event of an emergency, if you are unable to reach me at the above number, contact:

* 13. I make the following exception:

* 14. My child's Medications/Dosages:

* 15. In the event it comes to the attention of the Diocese of St. Augustine's employees, volunteers or representatives that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever or diarrhea, I hereby give permission for over-the-counter medication to be administered to my child according to directions

* 16. Parent/Guardian/Representative Signature & Date