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TYM Overnight Retreat March 8-10, 2024

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Your son/daughter is eligible to participate in the following activity that requires transportation to a location away from the parish site. This activity will take place under the guidance of adults from the parish of St. Matthew.

Activity: Youth Retreat
Location: Camp Chestnut Ridge, Efland, NC
Dates: March 8-10, 2024
Method of Transportation: parent drop off and pick up
Cost: $120 per youth

In order for your child to participate in this event, please complete and sign the following statement of consent and release of liability, medical information, photo release form, and contact information.
Parent Information
The maximum number of form submissions has been reached. This form is currently not available.
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Street Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Number of Youth Registering
  
  Youth Name REQUIRED Please fill out this field. Please enter valid data.
  
  Shirt Size REQUIRED Please fill out this field.
  
  Youth Cell Phone Please enter valid data.
  
  Youth Email Address Please enter valid data.
  
  Any allergies, medical, physical, or dietary restrictions/requirements REQUIRED Please fill out this field.
  
  Medications presently taking. Please include dosages and time for administration. REQUIRED Please fill out this field.
- Number of additional youth to register REQUIRED Please fill out this field.
  
  Youth 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Shirt Size REQUIRED Please fill out this field.
  
  Any allergies, medical, physical, or dietary restrictions/requirements REQUIRED Please fill out this field.
  
  Medications presently taking - please include dosage and time for administration REQUIRED Please fill out this field.
  
  Youth 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Shirt Size REQUIRED Please fill out this field.
  
  Any allergies, medical, physical, or dietary restrictions/requirements REQUIRED Please fill out this field.
  
  Medications presently taking - please include dosage and time for administration REQUIRED Please fill out this field.
  
  Youth 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Shirt Size REQUIRED Please fill out this field.
  
  Any allergies, medical, physical, or dietary restrictions/requirements REQUIRED Please fill out this field.
  
  Medications presently taking - please include dosage and time for administration REQUIRED Please fill out this field.
  
  Youth 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Shirt Size REQUIRED Please fill out this field.
  
  Any allergies, medical, physical, or dietary restrictions/requirements REQUIRED Please fill out this field.
  
  Medications presently taking - please include dosage and time for administration REQUIRED Please fill out this field.
  
  Youth 5
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Shirt Size REQUIRED Please fill out this field.
  
  Any allergies, medical, physical, or dietary restrictions/requirements REQUIRED Please fill out this field.
  
  Medications presently taking - please include dosage and time for administration REQUIRED Please fill out this field.
  
  Youth 6
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Shirt Size REQUIRED Please fill out this field.
  
  Any allergies, medical, physical, or dietary restrictions/requirements REQUIRED Please fill out this field.
  
  Medications presently taking - please include dosage and time for administration REQUIRED Please fill out this field.
- Statement of Consent & Release of Liability
  
  I understand that as a parent/guardian, I remain fully responsible for any liability that may result from personal actions taken by my son/daughter.
  
  If my youth brings or uses any drugs, alcohol, weapons, tobacco products, including vaping, or engages in reckless or violent behavior, I will be expected to retrieve my son/daughter from the event at my own expense.
  
  I hereby consent to the participation of my youth in the above-detailed event. I further consent to the conditions stated above regarding participation in this event, including the method of transportation.
  
  I release the Diocese of Raleigh, St. Matthew Catholic Church, and their agents and volunteers from any injuries which may be incurred by my youth.
  
  I give permission for my child, in case of emergency, to be taken to a physician or hospital by either an adult leader, diocesan or parish personnel. I understand that every effort will be made to contact me. If I cannot be reached, however, I hereby give permission to the physician selected by the adult in charge, to hospitalize and secure proper treatment, including surgery, for my son/daughter.
- I Agree Please select this field.
- Medical Insurance Information - please include policy holder, policy and group numbers REQUIRED Please fill out this field.
- Emergency Contact - other than parent: please provide name and phone number REQUIRED Please fill out this field.
- Retreat Fee per youth120.0
Total:

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