Confirmation Retreat Permission

Confirmation Retreat at Holy Spirit

Saturday October 12, 2024

9:00 AM to 4:00 PM

We welcome participants from other parishes at our Confirmation Retreat. Please complete the permission form below. If you have any questions, please contact the Director of Religious Education at [email protected]

Confirmation Retreat Permission

Youth Participant Name*
Please enter the full legal name of the child who will be attending.
First Middle Last
Other name
If your child is called by a different name than the first name, please enter it here. For example, if your child’s first name is “Nicholas” and prefers to be called “Nick,” please enter “Nick” below.
Gender*
- Male
- Female
Date of Birth*
School Grade*
Name of parish*
Please enter the name of your home parish – the parish where you are preparing for Confirmation.
Name of DRE*
What is the name of the person (e.g. the Director of Religious Education, or other person) who we should notify upon your attendance at the retreat?
First Last
Email Address of DRE*
What is the email address of the DRE (or other) whom we should be notifying?
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home / Family Email Address*
Father's Name*
First Last
Father's Contact Phone Number*
Mother's Name*
First Last
Mother's Contact Phone Number*
Parental Permission and Liability Release*
As parent/legal guardian of the participant named above, I give my permission to participate fully in the Confirmation Retreat from 9:00 AM to 4:00 PM on October 12, 2024. I agree to indemnify and hereby release the Most Reverend Michael F. Burbidge Bishop of the Catholic Diocese of Arlington and his successors in office, as well as the Catholic Diocese of Arlington and all Diocesan clergy, employees, volunteers, and participating parishes and schools from any and all liability, claims, demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned of the participant resulting from said participant’s involvement in the above mentioned event (including transportation to and from the event). Furthermore, I on behalf of the participant hereby assume all risk of personal injury, sickness, death, damage, and expenses resulting from said participant’s involvement in the above described event.
- I agree
Informed Consent to Medical Treatment*
As parent/legal guardian of the participant named above, I request that in my absence the above-named minor be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor. I assume full responsibility for all costs of such treatment. Further, should it be necessary for the participant to return home due to medical, disciplinary, or other reasons, I do hereby assume responsibility for the participant’s transportation home and any costs related thereto.
- I agree
Photo, Press, Audio, and Electronic Media Release*
As parent/legal guardian of the participant named above, I authorize the Catholic Diocese of Arlington, its parishes, its schools and/or the Arlington Catholic Herald to use and publish my child’s photograph, video and/or audio recording along with their name identifying them for educational, news stories, illustration and/or marketing purposes.
- I agree.
Alternate Emergency Contact*
First Last
Alternate Contact's Phone*
Relationship to Youth*
Health Information
Are there any medical conditions which may affect the participant’s involvement at the retreat? Are there any known allergies including any allergies to medicine?
Signature*
“I understand and hereby agree to the terms and conditions of the participant’s involvement at the Confirmation Retreat” Please type your name to digitally sign, acknowledging you have read and agree to the above listed waiver.
Confirmation Retreat (4112 RE Program Income)*
Retreat Cost
$0.00
Credit Card*
Card Details
Cardholder Name