2023 LITE Minor Release & Consent Form

Deadline: June 2, 2023
- The maximum number of form submissions has been reached. This form is currently not available.
  
  Parents/Guardians must complete and sumbit this form by June 2, 2023.
  
  Date: June 26-29, 2023 - Participants | June 25-29, 2023 - AYLT
  Location: Msgr. O'Dwyer Retreat House
  Address: 15523 York Road, Sparks, MD 21152
  
  RELEASE AND CONSENT FORM (Minors 18 and under)
  
  I,
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  the undersigned, give permission for my son/daughter
  
  Participant First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Participant Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  to attend L.I.T.E. It is understood that reasonable caution will be taken by those persons in charge to prevent injuries. In consideration of my child’s being permitted to participate in L.I.T.E., I personally and on behalf of my child, hereby release The Roman Catholic Archdiocese of Washington; Wilton Gregory, Roman Catholic Archbishop of Washington; a Corporation Sole: the Catholic Youth Organization of Washington, DC and Metropolitan Area, Inc; the Office of Youth Ministry; Msgr. O'Dwyer Retreat House their employees; volunteers, the coordinators and chaperones of
  
  Parish REQUIRED Please fill out this field.
  
  List Parish if "OTHER" Please enter valid data.
  
  parish/organization; from any liability for injuries or damages arising or resulting from participation in L.I.T.E., in and/or transportation to and there from. In the event that I cannot be reached, I hereby grant permission for my son/daughter to be evaluated, diagnosed, treated and/or medicated in accordance with standard medical practice by licensed medical personnel. Permission is hereby granted to L.I.T.E., The Roman Catholic Archdiocese of Washington to use the photographs and quotations of my son/daughter to assist in community awareness, educational efforts, related public relations purposed that may include brochures, posters, website and print media from L.I.T.E. My child agrees to abide by all rules and regulations as outlined in the Youth Code of Behavior. I understand that the Office of Youth Ministry and The Roman Catholic Archdiocese of Washington will not be held liable if my child fails to cooperate with said regulations and that any infractions of the rules may result in immediate dismissal from L.I.T.E.
  
  Check To Acknowledge REQUIRED I Agree Please fill out this field.
  
  YOUTH CODE OF BEHAVIOR
  
  The following guidelines will ensure a fun and safe experience for all of us:
  
  The possession of alcohol and illegal drugs is clearly prohibited and is cause for dismissal.
  
  The Parish/Organization is responsible for the overall actions of the participants.
  
  All participants, adults and youth, will be held to the highest Christian standards of morality.
  
  In the event that a behavior problem required disciplinary action, The Roman Catholic Archdiocese of Washington Adult chaperones or designee, along with the individual’s chaperone, will address the situation and make the necessary decision.
  
  As a member of my parish, I understand and agree to the Youth Code of Behavior. I also understand and agree that my parents or legal guardian will be notified at the time of any infractions requiring my dismissal from the event and that I will be sent home at my own and or parent’s/guardian’s expense.
  
  Check To Acknowledge REQUIRED I Agree Please fill out this field.
  
  PARTICIPANT INFORMATION
  
  Nickname / Name for Nametag: REQUIRED Please fill out this field. Please enter valid data.
  
  Gender REQUIRED Please fill out this field.
  
  T-Shirt Size REQUIRED Please fill out this field.
  
  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.
  
  Participant's Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Participant's Email REQUIRED Please fill out this field. Please enter an email address.
  
  Parent Guardian #1:
  
  Full Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone REQUIRED Please fill out this field. Please enter valid data.
  
  Work Phone Please enter valid data.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Parent/Guardian #2:
  
  Full Name Please enter valid data.
  
  Phone Please enter valid data.
  
  Work Phone Please enter valid data.
  
  Email Please enter an email address.
  
  EMERGENCY & MEDICAL INFORMATION
  
  My child is allergic to (medication/food/other):
  
  My child must take the following medications and will be bringing enough medication for: Please enter valid data.
  
  List Medications:
  
  Medication must be given to your parish adult chaperone to hold/administer.
  
  You should be aware of these special medical conditions/needs of my child:
  
  In the event that it comes to the attention of The Roman Catholic Archdiocese of Washington staff, its officers and agents or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever etc.
  
  I would like to be notified immediately REQUIRED Please fill out this field.
  
  No medication of any type (prescription or nonprescription) should be administered to my child unless the situation is life threatening and emergency treatment is required.
  
  I would like this followed REQUIRED Please fill out this field.
  
  EMERGENCY INFORMATION
  
  Name of Insurance Company REQUIRED Please fill out this field. Please enter valid data.
  
  Policy Holder REQUIRED Please fill out this field. Please enter valid data.
  
  Policy # REQUIRED Please fill out this field. Please enter valid data.
  
  Group # REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Last Tetanus Booster REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Minor REQUIRED Please fill out this field. Please enter valid data.
  
  Daytime Phone REQUIRED Please fill out this field. Please enter valid data.
  
  Evening Phone REQUIRED Please fill out this field. Please enter valid data.
  
  Submit
  
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2023 LITE Minor Release & Consent Form

RELEASE AND CONSENT FORM (Minors 18 and under)

YOUTH CODE OF BEHAVIOR

PARTICIPANT INFORMATION

EMERGENCY & MEDICAL INFORMATION

EMERGENCY INFORMATION