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Life Teen Summer Retreat on Friday, August 8, 2025 @ 5:00 PM

Price:

*Attendee's First Name:

*Attendee's Last Name:

*Attendee's Email Address:

*Attendee's Phone Number:

Country:

Address Line 1:

Address Line 2:

City, State Zip:

*Participant's Name:

*Grade Level:

*School Attended:

*Gender:

*Date of Birth:

*Parent(s) Name:

*Parent Email:

EMERGENCY MEDICAL AUTHORIZATION (Ohio Revised Code 3313.712) Purpose: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under Holy Martyrs authority, when parents or guardians cannot be reached. This information will be shared, as necessary, with youth ministers, parish administrative staff and medical personnel.

*Medical Information:

*Allergy Info:

*Medication(s) & Instructions:

*Medical Partners:

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for: 1) the administration of any treatment deemed necessary by above named doctors, or, in the event the designated practitioner is not available, by another licensed physician or dentist; and 2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the authorities to take the following action

*Emergency Contact Name:

*Emergency Contact Info:

*Emergency Contact Relationship to Teen:

*I/we hereby give consent to photograph or videotape aforesaid student and without limitation to use such photographs or videotapes and stories in connection with any work of the Holy Martyrs Church without consideration of any kind, and I do hereby release

Registration Total: