Extreme Faith Camp Registration

Participant Name

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Date of Birth (MM/DD/YYYY) REQUIRED Please fill out this field. Please enter a date.

Select Grade REQUIRED Please fill out this field.

Please select your parish REQUIRED Please fill out this field.

Sex REQUIRED Please fill out this field.

T-Shirt Size REQUIRED Please fill out this field.

Parent/Guardian Name

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Parent/Guardian Email Address REQUIRED Please fill out this field. Please enter an email address.

Home Address REQUIRED Please fill out this field. Please enter valid data.

Parent Phone Number REQUIRED Please fill out this field. Please enter a phone number.

By checking "I agree" I, the parent/guardian named above, grant permission for my child, the participant named above, to participate in this parish event that requires transportation to a location away from the parish site. This activity will take place under the guidance and direction of parish employees and/or volunteers from Holy Family Catholic Church.

I understand and agree that as parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above-named minor (“participant”). I understand that my child is required to comply with the Code of Conduct provided by the parish/school while participating in the event. I understand and agree that if my child violates the Code of Conduct he/she may be required to be transported home at my expense. I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend Holy Family Catholic Church, its officers, directors, employees and agents, and the Archdiocese of Saint Paul and Minneapolis, its employees and agents, chaperones, or representatives associated with the event and activities (hereinafter “Releasees”), from any claims, including but not limited to all claims relating to communicable disease, arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate Releasees for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of Releasees.

Agreement REQUIRED I Agree Please fill out this field.

MEDICAL MATTERS: I 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.

Medical Matters REQUIRED I Agree Please fill out this field.

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:

Emergency Contact First and Last Name REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact's Relationship to Participant REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Family Doctor REQUIRED Please fill out this field. Please enter valid data.

Family Doctor Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Family Health Plan Carrier REQUIRED Please fill out this field. Please enter valid data.

Health Plan Policy Number REQUIRED Please fill out this field. Please enter valid data.

Emergency Medical Treatment Agreement REQUIRED I Agree Please fill out this field.

Other Medical Treatment: In the event it comes to the attention of the parish/school, its officers, directors and agents, and the Archdiocese of Saint Paul and Minneapolis, chaperones, or representatives associated with the activity, that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called as soon as it is reasonably possible.

Other Medical Treatment Notification (Not required) I would like a call as soon as reasonably possible

Medications: My child is taking medication at present. My child will bring all such medications necessary and such medications will be well-labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage, are as follows:

Name of Prescription/Medicine Please enter valid data.

Prescribing Doctor Please enter valid data.

Amount of Dosage Please enter valid data.

Times to be Given Please enter valid data.

Duration of Prescription Please enter valid data.

I hereby authorize a chaperone from Holy Family Catholic Church or an authorized camp nurse to dispense medicine to my participant as directed above.

Prescription Drug and Medicine Authorization I Agree

No medication of any type, whether prescription or non-prescription, may be administered to my child unless the situation is life-threatening and emergency treatment is required. I Agree

I hereby grant permission for non-prescription medication (i.e. non-aspirin products such as acetaminophen or ibuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate. I Agree

Specific Medical Information: The parish/school will take reasonable care to see that the following information will be held in confidence.

Allergic reactions (medications, foods, plants, insects, etc.) Please enter valid data.

Immunizations: Date of last tetanus/diphtheria immunization Please enter valid data.

Does child have a medically prescribed diet? Please enter valid data.

Does child have any physical limitations? Please enter valid data.

Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, bedwetting, fainting? Please enter valid data.

Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? REQUIRED Yes No Please fill out this field.

If so, list date and disease or condition: Please enter valid data.

You should be aware of these special medical conditions of my child: Please enter valid data.

As Parent or Guardian, I agree to all of the above stated considerations and conditions. REQUIRED I agree Please fill out this field.

I am requesting a scholarship (If you are requesting a scholarship, please also email [email protected]) I would like to be considered for a scholarship

Registration Payment REQUIRED

Total Cost $465

$ Please fill out this field. Please enter a positive decimal.