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Life Teen Summer Retreat on Saturday, August 9, 2025

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*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:
*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