High School December Retreat

Phone

This field is for validation purposes and should be left unchanged.

Date of Registration*

Mother's Name*

First Middle Last

Mobile Phone*

Primary Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Email*

Father's Name*

First Middle Last

Mobile Phone*

Personal Email*

Address (if different than above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Child's Information

How many children are you registering?*

Name of Child #1*

First Middle Last

Gender*

Date of Birth*

Grade in 2026-2027*

Permission to Contact Youth

I hereby grant permission for Mary Our Queen to contact my child, for internal or external communications until May 31,2027 via social media, email, text, and/or parish/school-approved online/virtual platforms. I understand I can request the same communications provided to my child, and that it does not have to be via the same technology (for example, if children receive a reminder via Twitter, parents can receive it in a printed form or by an email list).

I DO NOT GRANT PERMISSION TO CONTACT MY CHILD

Student Email

Student Cell

Student Sweatshirt Size

Medium
Large
XL
2XL

Emergency Medical Release

I/We do hereby, for myself, my heirs, executors, and administrators, waive, release, absolve, indemnify and agree to hold harmless any and all adults who chaperone, also the Archdiocese and its representatives, successors,
supervisors, sponsors, organizers and participants for any injuries in connection with the program named above.
I/We also give permission to seek any emergency care should my child be involved in any accident or be injured in any way during such events named above. I/We understand that in any such instance, all attempts will be made to contact the parent/guardian. In the event that I/we cannot be contacted, I/we hereby give permission to the attending physician to hospitalize, secure treatment for, and to order injection, anesthesia, and/or surgery for my child, as named herein. I also agree that I am legally responsible for all/any personal actions taken by my child/guardianship during this event, and agree to be financially responsible for any/all damages, legal fees, and other costs incurred as a result of the actions/behavior of my child/guardianship. Furthermore, I/we agree that if the above named student’s behavior is inappropriate, unsafe and/or detrimental to the group, I will be contacted immediately to secure means of removing my child/guardianship from the event premises. I understand that any financial costs incurred as a result of my child/guardianship being sent home are my responsibility.

I DO NOT CONSENT TO THE EMERGENCY MEDICAL RELEASE

Does your child have any allergies or health concerns that we need to know about?*

Is your child taking any medication? Please list below*

Does your child have any drug allergies? Please list below*

I hereby grant permission for non prescription medication to be given, if deemed appropriate*

Yes
No

Media Policy

Mary Our Queen uses images, interviews, and videos of our children for a variety of internal and external communications. Our forms of internal and external communications include but are not limited to: print, such as newspapers, bulletins, and newsletters; photographs and digital images; film and videos; web posts, web pages, and image carousels.
I hereby grant permission for Mary Our Queen to use images and interviews of my child for internal or external communications.

I DO NOT AGREE TO THE MEDIA POLICY

Name of Child #2*

First Middle Last

Gender*

Date of Birth*

Grade in 2026-2027*

Permission to Contact Youth

I hereby grant permission for Mary Our Queen to contact my child, for internal or external communications until May 31,2027 via social media, email, text, and/or parish/school-approved online/virtual platforms. I understand I can request the same communications provided to my child, and that it does not have to be via the same technology (for example, if children receive a reminder via Twitter, parents can receive it in a printed form or by an email list).

I DO NOT GRANT PERMISION TO CONTACT MY CHILD

Student Email

Student Cell

Student Sweatshirt Size

Medium
Large
XL
2XL

Emergency Medical Release

I/We do hereby, for myself, my heirs, executors, and administrators, waive, release, absolve, indemnify and agree to hold harmless any and all adults who chaperone, also the Archdiocese and its representatives, successors,
supervisors, sponsors, organizers and participants for any injuries in connection with the program named above.
I/We also give permission to seek any emergency care should my child be involved in any accident or be injured in any way during such events named above. I/We understand that in any such instance, all attempts will be made to contact the parent/guardian. In the event that I/we cannot be contacted, I/we hereby give permission to the attending physician to hospitalize, secure treatment for, and to order injection, anesthesia, and/or surgery for my child, as named herein. I also agree that I am legally responsible for all/any personal actions taken by my child/guardianship during this event, and agree to be financially responsible for any/all damages, legal fees, and other costs incurred as a result of the actions/behavior of my child/guardianship. Furthermore, I/we agree that if the above named student’s behavior is inappropriate, unsafe and/or detrimental to the group, I will be contacted immediately to secure means of removing my child/guardianship from the event premises. I understand that any financial costs incurred as a result of my child/guardianship being sent home are my responsibility.

I DO NOT CONSENT TO THE EMERGENCY MEDICAL RELEASE

Does your child have any allergies or health concerns that we need to know about?*

Is your child taking any medication? Please list below*

Does your child have any drug allergies? Please list below*

I hereby grant permission for non prescription medication to be given, if deemed appropriate*

Yes
No

Media Policy

Mary Our Queen uses images, interviews, and videos of our children for a variety of internal and external communications. Our forms of internal and external communications include but are not limited to: print, such as newspapers, bulletins, and newsletters; photographs and digital images; film and videos; web posts, web pages, and image carousels.
I hereby grant permission for Mary Our Queen to use images and interviews of my child for internal or external communications.

I DO NOT AGREE TO THE MEDIA POLICY

Name of Child #3*

First Middle Last

Gender*

Date of Birth*

Grade in 2026-2027*

Permission to Contact Youth

I hereby grant permission for Mary Our Queen to contact my child, for internal or external communications until May 31,2027 via social media, email, text, and/or parish/school-approved online/virtual platforms. I understand I can request the same communications provided to my child, and that it does not have to be via the same technology (for example, if children receive a reminder via Twitter, parents can receive it in a printed form or by an email list).

I DO NOT GRANT PERMISION TO CONTACT MY CHILD

Student Email

Student Cell

Student Sweatshirt Size

Medium
Large
XL
2XL

Emergency Medical Release

I/We do hereby, for myself, my heirs, executors, and administrators, waive, release, absolve, indemnify and agree to hold harmless any and all adults who chaperone, also the Archdiocese and its representatives, successors,
supervisors, sponsors, organizers and participants for any injuries in connection with the program named above.
I/We also give permission to seek any emergency care should my child be involved in any accident or be injured in any way during such events named above. I/We understand that in any such instance, all attempts will be made to contact the parent/guardian. In the event that I/we cannot be contacted, I/we hereby give permission to the attending physician to hospitalize, secure treatment for, and to order injection, anesthesia, and/or surgery for my child, as named herein. I also agree that I am legally responsible for all/any personal actions taken by my child/guardianship during this event, and agree to be financially responsible for any/all damages, legal fees, and other costs incurred as a result of the actions/behavior of my child/guardianship. Furthermore, I/we agree that if the above named student’s behavior is inappropriate, unsafe and/or detrimental to the group, I will be contacted immediately to secure means of removing my child/guardianship from the event premises. I understand that any financial costs incurred as a result of my child/guardianship being sent home are my responsibility.

I DO NOT CONSENT TO THE EMERGENCY MEDICAL RELEASE

Does your child have any allergies or health concerns that we need to know about?*

Is your child taking any medication? Please list below*

Does your child have any drug allergies? Please list below*

I hereby grant permission for non prescription medication to be given, if deemed appropriate*

Yes
No

Media Policy

Mary Our Queen uses images, interviews, and videos of our children for a variety of internal and external communications. Our forms of internal and external communications include but are not limited to: print, such as newspapers, bulletins, and newsletters; photographs and digital images; film and videos; web posts, web pages, and image carousels.
I hereby grant permission for Mary Our Queen to use images and interviews of my child for internal or external communications.

I DO NOT AGREE TO THE MEDIA POLICY

Name of Child #4*

First Middle Last

Gender*

Date of Birth*

Grade in 2026-2027*

Permission to Contact Youth

I hereby grant permission for Mary Our Queen to contact my child, for internal or external communications until May 31,2027 via social media, email, text, and/or parish/school-approved online/virtual platforms. I understand I can request the same communications provided to my child, and that it does not have to be via the same technology (for example, if children receive a reminder via Twitter, parents can receive it in a printed form or by an email list).

I DO NOT GRANT PERMISION TO CONTACT MY CHILD

Student Email

Student Cell

Student Sweatshirt Size

Medium
Large
XL
2XL

Emergency Medical Release

I/We do hereby, for myself, my heirs, executors, and administrators, waive, release, absolve, indemnify and agree to hold harmless any and all adults who chaperone, also the Archdiocese and its representatives, successors,
supervisors, sponsors, organizers and participants for any injuries in connection with the program named above.
I/We also give permission to seek any emergency care should my child be involved in any accident or be injured in any way during such events named above. I/We understand that in any such instance, all attempts will be made to contact the parent/guardian. In the event that I/we cannot be contacted, I/we hereby give permission to the attending physician to hospitalize, secure treatment for, and to order injection, anesthesia, and/or surgery for my child, as named herein. I also agree that I am legally responsible for all/any personal actions taken by my child/guardianship during this event, and agree to be financially responsible for any/all damages, legal fees, and other costs incurred as a result of the actions/behavior of my child/guardianship. Furthermore, I/we agree that if the above named student’s behavior is inappropriate, unsafe and/or detrimental to the group, I will be contacted immediately to secure means of removing my child/guardianship from the event premises. I understand that any financial costs incurred as a result of my child/guardianship being sent home are my responsibility.

I DO NOT CONSENT TO THE EMERGENCY MEDICAL RELEASE

Does your child have any allergies or health concerns that we need to know about?*

Is your child taking any medication? Please list below*

Does your child have any drug allergies? Please list below*

I hereby grant permission for non prescription medication to be given, if deemed appropriate*

Yes
No

Media Policy

Mary Our Queen uses images, interviews, and videos of our children for a variety of internal and external communications. Our forms of internal and external communications include but are not limited to: print, such as newspapers, bulletins, and newsletters; photographs and digital images; film and videos; web posts, web pages, and image carousels.
I hereby grant permission for Mary Our Queen to use images and interviews of my child for internal or external communications.

I DO NOT AGREE TO THE MEDIA POLICY

Emergency Contact

Name*

First Last

Relationship*

(neighbor, friend, grandparent, etc.)

Emergency Contact's Phone Number*

Insurance Information

Insurance Carrier

Name on Policy

Relationship to Participant

Policy Number

Group Number

Parent Signature*

I have read and understand all consents for each child I wish to register.

High School December Retreat

High School Retreat Registration 2026

Child's Information

Emergency Contact

Insurance Information