Echoes of Worth 2019- TEEN REGISTRATION
Details
Location: Mission Springs Retreat Center
Address: 1050 Lockhart Gulch Road, Scotts Valley, CA 95066
Contact Name: Andrew Brown
Dates: Friday, January 18 – Sunday, January 20, 2019.
A multi-parish, multi-diocese weekend with guest speakers, music, Mass, workshops, small groups, prayer experiences, and more.
Email address *
Teenager First Name *
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Teenager Last Name *
Your answer
Have you attended the Echoes of Worth retreat before? *
Home Address *
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School *
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Teenager phone # *
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Teenager E-mail Address *
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Current Grade *
Student shirt size *
Gender *
Parent 1 Name *
Your answer
Parent Telephone *
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Parent E-mail Address *
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Parent 2 name *
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Parent Telephone *
Your answer
E-mail address *
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Parish Name *
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Diocese: *
Parish Youth Minister Name
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Parish Youth Minister Email address
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Medical plan name *
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Policy number *
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Medical plan address *
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Medical plan telephone *
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Doctor's name *
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Doctor's telephone *
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Emergency contact (other than parent) name *
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Emergency contact telephone *
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Emergency contact 2 (other than parent) name *
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Emergency contact 2 telephone *
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BY CHECKING THE BOX BELOW, I CERTIFY THAT I AM THE PARENT OR LEGAL GUARDIAN OF THE CHILD NAMED ABOVE. I HOLD THE ECHOES OF WORTH MINISTRY AND DIOCESE OF SAN JOSE HARMLESS FROM ANY CLAIM OF INJURY, SICKNESS, ILLNESS OR DAMAGE THAT MY CHILD MAY SUFFER OR SUSTAIN DURING THE ACTIVITY LISTED ABOVE, WITH EXCEPTION TO INJURY OF DAMAGES ARISING OUT OF THE SOLE NEGLIGENCE OF THE ECHOES OF WORTH OR DIOCESE OF SAN JOSE. I ATTEST THAT MY CHILD IS PHYSICALLY FIT TO PARTICIPATE IN THIS EVENT. IN THE EVENT MY CHILD BECOMES ILL OR INJURED, I DO HEREBY CONSENT TO WHATEVER X-RAY, EXAMINATION, MEDICAL OR TREATMENT AND HOSPITAL CARE ARE CONSIDERED NECESSARY IN THE BEST JUDGEMENT OF THE ATTENDING PHYSICIAN AND PERFORMED BY OR UNDER THE SUPERVISION OF A MEMBER OF THE MEDICAL STAFF OF THE HOSPITAL FACILITY PROVIDING THE TREATMENT. I AM NOT AWARE OF ANY MEDICAL CONDITION WHICH WOULD RENDER IT INAPPROPRIATE FOR MY CHILD TO PARTICIPATE IN ANY SUCH ACTIVITY. *
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PICTURES & VIDEO ARE TAKEN OF YOUTH MINISTRY EVENTS AND GATHERINGS. WE WOULD LIKE TO BE ABLE TO USE THESE PHOTOGRAPHS FOR NEWSLETTERS, FLYERS, AND THE ECHOES OF WORTH MINISTRY WEB SITE. WE WILL NOT USE ANY LAST NAMES IF POSTED. CONCERNS ABOUT PUBLISHED PICTURES SHOULD BE EXPRESSED TO WRITER/ WEBMASTER AND WILL BE PROMPTLY DEALT WITH. BY CHECKING THE BOX BELOW, I CERTIFY THAT I/WE THE PARENT(S) OF THIS STUDENT, AUTHORIZE AND GIVE FULL CONSENT, WITHOUT LIMITATION OR RESERVATION, THE ECHOES OF WORTH MINISTRY, TO PUBLISH ANY PHOTOGRAPHS IN WHICH THE ABOVE NAMED STUDENT APPEARS WHILE PARTICIPATING IN ANY PROGRAM WITH DIOCESE OF SAN JOSE ECHOES OF WORTH RETREAT. NO COMPENSATION IS TO BE GIVEN. *
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Are there any known allergies to food that those who work with your young person this week should be aware of? If yes, please explain. If no, please leave blank.
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Are there any known allergies to medications that those who work with your young person this week should be aware of? If yes, please explain. If no, please leave blank. *
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Does the participant have any special dietary needs? If yes please list. *
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Are there any known physical, psychological or emotional limitations that would affect this young person’s participation in this event? *
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Any medication not able to be self-administered must be listed. *
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