Read this carefully!!!

Transcription

1 Our Lady of Hope Church Our Lady of Hope Youth Group MAY 3, 2015 Adult Participants Over 26 Years of Age: Read this carefully!!! If you wish to participate in the Wisconsin Summer Service Trip you MUST do the following; 1. GET THE ALL FORMS COMPLETELY FILLED IN. 2. ATTACH COPIES OF THE FRONT AND BACK OF MEDICAL INSURANCE AND PRESCRIPTION CARDS AND A DRIVERS LICENSE OR STAE I.D. CARD. 3. RETURN THE THREE PERMISSION SLIPS, I.D. COPY, THE MEDICAL CARD COPIES TO OUR LADY OF HOPE NO LATER THAN 11:00 A.M. ON June 7, PUT THE ABOVE IN AN ENVELOPE ADDRESSED TO DEACON JIM AND TURN INTO THE OFFICE. 5. SEE ATTACHED LIST OF ITEMS TO BRING. PACKING IS LIMITED, SO PLEASE BRING ONLY THE NECESSITIES. ALL CLOTHING MUST BE MODEST IN NATURE. 7. YOU MAY WANT TO BRING ABOUT $20-$40 CASH FOR SPENDING. WE MAY BE GOING SOME PLACES AND YOU MAY WANT TO SHOP. 8. WE WILL RETURN APPROXIMATELY 2:00 P.M. ON JULY 25, PLEASE ARRANGE FOR PROMPT PICK-UP AT THE OUR LADY OF HOPE PARKING LOT. DEACON JIM Trip Emergency Numbers: Deacon Jim: ; Mrs. Ernst: ; Mr. Kaisling: ; Camp Daniel Office: KEEP THIS PAGE - DO NOT TURN IN

2 Our Lady of Hope Church Our Lady of Hope Youth Group Permission Slip adult 26 or older Summer Service Trip to Athelstane, WI. / / PARTICIPANT NAME DATE OF BIRTH (MM/DD/YYYY) HOME PHONE NUMBER I,, will be a participant in the 2015 Our Lady of Hope Youth Group Summer Service Trip to Athelstane, WI during the period of July 19, 2015 until July 25, I understand that participation in this trip includes car, van, and and/or bus transportation; the use of tools, both power and manual, and assorted implements all of which may have inherent risks. I hereby release and indemnify the staff and volunteers of Our Lady of Hope parish; the Catholic Bishop of Chicago, an Illinois corporation sole; Camp Daniel, Inc. of Athelstane, WI; and all other properties and volunteers associated with this Our Lady of Hope Youth Group function, from any and all liability arising from claims of any kind or nature, whatsoever, from my participation in this event and all activities associated with this trip. I understand that I am subject to acceptable rules of behavior while on this activity. I also understand that I will be required to leave the activity location, if I fail to act in a proper manner. I also agree that improper actions will be judged at the discretion of the Our Lady of Hope Parish delegated adult leaders of this activity. Should I be injured, I give the adult leaders my permission to have any emergency care given to me in the event that my emergency contacts/physician cannot be immediately contacted. I also agree to inform the Youth Group Coordinator at Our Lady of Hope Church of any changes to the following information. I authorize Our Lady of Hope Church/Youth Ministry to use my picture, without my name, for educational and marketing purposes. This permission may be rescinded by written request to Our Lady of Hope Youth Ministry. The participant agrees to be at Our Lady of Hope Church at 9:00 a.m. on July 19, 2015, attend 9:30 a.m. Mass and the participant will be prepared to depart after Mass. This form and all other related documents needed for participation must be turned in no later than 11:00 a.m. on June 7, PARTICIPANT S SIGNATURE DATE MEN S T SHIRT SIZE WITNESS TO ABOVE SIGNATURES (AN ADULT OVER 21 MUST SIGN) DATE EMERGENCY CONTACTS 1) PHONE NUMBER 2) PHONE NUMBER NOTE: THIS PERMISSION SLIP MUST BE USED, NO OTHER WRITTEN OR PHONE PERMISSION WILL BE ACCEPTED. Our Lady of Hope Church

3 Our Lady of Hope Youth Group Medical permission form over 18 yrs. old Our lady of hope youth group trip To Athelstane, WI July 20-26, 2014 I, hereby grant permission for the administration of medical treatment and/or first aid to me by any adult volunteer involved in the above stated activity and by those transporting me, as part of this activity, as their judgment deems advisable. I grant permission for these same individuals to make any necessary referrals to qualified physicians for the treatment of illness or accidents of a more serious nature. I understand that my emergency contact or my parent/guardian, if responsible for my health insurance, will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when a delay in such communication would endanger my life and that in case of such a medical emergency, I understand that every effort will be made to contact same as soon as possible. In the event that they cannot be reached, I hereby give permission to the physician selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery, if deemed necessary for my treatment. I also understand that I have not been given any guarantee as to the results of examination or treatment. Signature of Participant Date Address City State ZIP Home Telephone Work Telephone Other Contact: Cell Phone/Pager Authorized Physician (Print Name) Insurance Company Phone Number Policy Number Please list any medical concerns, allergies and or medications you are currently taking. YOU MUST ATTACH COPIES OF BOTH FRONT AND BACK OF YOUR INSURANCE AND PRESCRIPTION CARDS AND A PHOTO COPY OF A CURRENT I.D. OF THE PERSON WHO'S NAME APPEARS ABOVE.

4 our Lady of Hope youth group summer service trip personal material list Each participant should bring the following items on the Summer Service Trip: (Clothing is for six days) Sleeping Bag Sleeping Attire Pillow (Only One) Construction Type Work Boots --Must be worn on the work site. Work Pants (2-3 pr.) --Must be worn on the work site. 5 T-shirts for the work site no exposed midriff. Plastic (Emergency) Rain Poncho Clothes to relax in after work. --Shorts, Gym shoes, etc. --Modesty will be in force Socks, thick, above ankle or boot top. Underwear Sweatshirt or light jacket 1 or two hats for the worksite 1 set of nice casual clothes --for our night out for dinner. Medications you need Back Pack for the trip Swim suit--modesty!! Extra Batteries for your needs & electronics One Bag with all your clothes, etc. Sunglasses Sun Screen Insect Repellant Bath Towel Toothbrush Toothpaste Soap Shampoo Other needed Personal Hygiene Items Beach Towel Camera --put your name on it. Leather Gloves - Labeled with name Safety Goggles ($ Store)--put your name on it 1Qt. Refillable Water Bottle No pre-packaged water in bottles Cookies 1 package to serve 12 people. Lunch and drink for ride to Camp Daniel We will also need four Boom Boxes for the group, two for the work site. Notes: KEEP THIS PAGE - DO NOT TURN IN Our Lady of Hope Church

5 Youth Group Adult participation over 26 All Events JULY 2015 JUNE 2016** I, plan to attend any or all of the Our Lady of Hope Youth Group activities from July 1, 2015 until June 30, I understand that signing this permission slip does not require me to attend all scheduled events. I understand that participation in these activities may include car, van, and and/or bus transportation; the use of tools, both power and manual, and assorted implements all of which may have inherent risks. I hereby release and indemnify the staff and volunteers of Our Lady of Hope parish, and the Catholic Bishop of Chicago, an Illinois corporation sole, and all other properties and volunteers associated with these Our Lady of Hope Youth Group functions, from any and all liability arising from claims of any kind or nature, whatsoever, from the above person s participation in these events and all activities associated with these events. I understand that I am subject to acceptable rules of behavior while on these activities. I also understand that I will be required to leave any activity location, if I fail to act in a proper manner. I also agree that improper actions will be judged at the discretion of the adult leaders of each activity. Should I be injured, I give the adult leaders my permission to have any emergency care given I understand that the person responsible for my insurance, if not myself, will be contacted in a reasonable amount of time and that one of my emergency contact s will also be contacted. I also agree to inform the Youth Group Coordinator at Our Lady of Hope Church of any changes to the following information. ( Initial) I authorize Our Lady of Hope Church/Youth Ministry to use my picture for educational and marketing purposes and these pictures may be published on the Our Lady of Hope Website, Facebook Page and/or in the Our Lady of Hope Bulletin, without the use of my name. I also give permission for Deacon James Ernst, Mrs. Rose Ernst, Mr. William Kaisling and/or Ms. Kimberly Rose permission to communicate directly with me about Youth Group or Church business through electronic means, including and/or text messaging or cell phone contact. Any part of this permission may be rescinded by written request to Our Lady of Hope Youth Ministry, Attention Fr. John Clemens. ( Initial) PLEASE BE PROMPT!!! Participants should arrive at Our Lady of Hope Church at the time stated for each event. Rides will leave five minutes after that time. Reservations are needed for each event. It is the responsibility of each participant to inform the coordinator for each event, in advance, if they will be attending. PARTICIPANT S SIGNATURE PARTICIPANT S DATE PARTICIPANT S STREET ADDRESS CITY ZIP MEN S T SHIRT SIZE / / PARTICIPANT S HOME PHONE PARTICIPANT S CELL PHONE PARTICIPANT S D.O.B (mm/dd/yyyy) EMERGENCY PHONE #1 EMERGENCY PHONE #2 MEDICAL INFORMATION: INSURANCE COMPANY NAME POLICY NUMBER DOCTOR S NAME PHONE NUMBER MISC. MEDICAL INFORMATION: PHYSICAL RESTRICTIONS, ALLERGIES, CURRENT MEDICATIONS, AND MEDICATIONS YOU ARE ALLOWED TO TAKE AT ANY TIME: (Include over-the-counter medications.) **THIS PERMISSION SLIP MUST BE USED, NO OTHER WRITTEN OR PHONE PERMISSION WILL BE ACCEPTED. EMERGENCY CONTACT DURING THE EVENTS: Cell Phone: , unless otherwise stipulated.