2023 SMYRT Online Registration

Archdiocese of Galveston/Houston
St Matthias Catholic Church High School Spring Retreat

GENERAL INFORMATION

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

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

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.

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

Parent/Guardian REQUIRED Please fill out this field. Please enter valid data.

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

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

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

Student's Email REQUIRED Please fill out this field. Please enter an email address.

Sex REQUIRED Male Female Please fill out this field.

Grade? REQUIRED 9th 10th 11th 12th Please fill out this field.

AGE? REQUIRED 14 15 16 17 18 Please fill out this field.

T-Shirt Size (Adult Sizes Only) REQUIRED X-Small Small Medium Large X-Large Please fill out this field.

CONSENT & LIABILITY WAIVER

Signing Parent:

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

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

Other Parent (not signing):

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 Signed REQUIRED Please fill out this field. Please enter a date.

Important! To be filled out by the Parent/Guardian for youth under 18 years of age. If participant is 18 years of age or older, consent must be signed/agreed by that individual.

I agree on behalf of myself, my child's other parent if known or living. My child named herein, or our heirs, successors, and assigns, to hold harmless and defend the Archdiocese of Galveston-Houston, St. Matthias Catholic Church (its pastor, youth minister, other agents, etc.), the sponsoring parish (its pastor, youth minister, other agents, etc.) or any representatives associated with the schedule activity unless the parties involved were careless or negligent.

I Agree Please select this field.

PHOTOGRAPHY CONSENT

St. Matthias the Apostle Catholic Church

As parent/guardian, I understand that promotional pictures (individual and group) will be taken during this event. I give permission for my son's/daughter's picture to be used for promotional materials (newsletter, web page, calendars, power point, etc. ) in highlighting the event.

I Agree Please select this field.

S M Y R T
St. Mary's Youth Retreat Team
Media Consent Form

I hereby give my consent and permission for my son/daughter to be photographed during St. Mary's Youth Retreat Team activities. I understand that photos and/or videos may be used for future publicity of St. Mary's Youth Retreat Team. Publicity may include, but is not limited to: mailings, brouchures, website postings (www.aggiecatholic.org) and/or possible promotion video usage.

I Agree Please select this field.

MEDICAL CONSENT

MEDICAL MATTERS
I hereby warrant to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. Of the following statements pertaining to the medical matters, sign only those in accordance with your wishes:

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 and you are unable to reach me, please contact:

Emergency Contact Name & Relationship:

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 Please fill out this field. Please enter a phone number.

Relationship REQUIRED Family Friend Please fill out this field.

Family Doctor:

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 Please fill out this field. Please enter a phone number.

I fully understand the foregoing statements and sign this Parental/Guardian Medical Consent Waiver knowingly, freely, and willingly.

I Agree Please select this field.

MEDICATIONS:
My child will bring all such medicatons, well labeled, that are necessary. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency are as follows.

My child is taking the following medication at the present time:

Medications | Dosage | Administer Instructions: REQUIRED Please fill out this field.

Administration REQUIRED I hereby DO NOT GRANT Permission for medication of any type, whether prescription or nonprescription, to be administered by my child unless the situation is life threatening and emergency treatment is required. I hereby GRANT PERMISSION for nonprescription medication (such as Tylenol, throat lozenges, cough syrup) to be given to my child, if deemed advisable. I understand that Aspirin will not be given to my son/daughter. Please fill out this field.

Medical Conditions Information
(Parish personnel will take reasonable care to see that the following ingormation will be held in confidence.)

My Son/Daughter has:

Has had an episode of the following or has been diagnosed: REQUIRED Seizures Asthma Diabetic None of the above Please fill out this field.

Additional Explanation:

Insurance Information

Do you carry Medical Insurance for your child? REQUIRED No, I do not carry medical insurance at this time. Yes, we carry medical insurance. Details provided below. I will provide an image copy (front & back) of our Insurance Card to Sylvia Perez. Please fill out this field.

Insurance Carrier Please enter valid data.

Name of Insured Please enter valid data.

Insurance ID Number REQUIRED Please fill out this field. Please enter valid data.

Insurance Policy Number Please enter valid data.

Father's Name Please enter valid data.

Father's Place of Employment Please enter valid data.

Father's Birthdate Please enter a date.

Mother's Name Please enter valid data.

Mother's Place of Employment Please enter valid data.

Mother's Birthdate Please enter a date.

I testify that the above Insurance information is accurate. Additionally, I accept that it is my responsibility to deliver an image copy (front & back) of our Insurance Card to Sylvia Perez.

I Agree Please select this field.

ILLNESS: In the event it comes to the attention of the chaperones associated with the activity that my child becomes ill with repeated symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called immediately. If this will be a long distance call, I want to be called collect (with phone charges reversed to myself).
I fully understand the foregoing statements and sign this Parental/Guardian Medical Consent Waiver knowingly, freely, and willingly.

I Agree Please select this field.

REGISTRATION PAYMENT
(Please consider helping by covering the 3% online transaction fee)

Registration Payment REQUIRED Please fill out this field.