PARENT (please type or print)

I, _______________________________________, (Parent [ ] Legal Guardian [ ]) undersigned, give my permission for my son/daughter __________________________ to attend the Journey Retreat Weekend to be held at the Emmanual Retreat House in Glenmont, NY from Thursday evening March 19, 2009 to Sunday evening, March 22, 2009 and if needed to be evaluated, diagnosed, treated, and/or medicated in accordance with standard medical practice by licensed medical personnel.

I relieve the parish of _________________________ and the Diocese of Albany and the Emmanual Retreat House and the Journey Retreat Program of St. Helen's of all responsibility and consequences which may arise as a result of this treatment.

I will not hold the above parish, nor the Diocese of Albany, the Emmanual Retreat House, chaperones, Spiritual Directors or representatives associated with the retreat responsible in the event of injury. Further, I agree to accept any and all financial responsibility as a result of scheduling such treatment.

My child agrees to abide by all rules and regulations decided upon by the above parish, the Diocese of Albany, the Emmanual Retreat House and the Journey Retreat Program of St. Helen's. I understand that neither the above parish nor the Journey Retreat Program of St. Helen's will be held liable if my child fails to cooperate with said regulations and that any infraction of the rules may result in immediate dismissal from the Journey Retreat Weekend. I further understand that I will be responsible for any costs of other requirement for immediate transportation home.

YOUTH

As a member of the above parish, I _________________________, understand and agree to the rules and regulations as determined by the Diocese of Albany, the parish, the Emmanual Retreat House and the Journey Retreat Program of St. Helen's. I also understand and agree that I will notify my parents/guardians at the time of any infractions requiring my dismissal from the Retreat weekend and that I will be sent home at my own and/or my parent's/guardian's expense.

____________________________________________ Date ______________
Signature of Parent/Guardian

____________________________________________ Date ______________
Signature of Youth Participant

NOTE: Please also complete the information on Page 2

Page 1 of 2

Thank you for taking the time to complete this page.
It will help to ensure the safety of your son or daughter.

YOUTH'S MEDICAL INFORMATION:

Allergies ______________________________________________________________

Required Medications __________________________________________________
(please include dosages, frequency, etc.)

Special Medical Conditions_______________________________________________

___________________________________________________________

Special Dietary Considerations or Restrictions:

___________________________________________________________

Date of Last Tetanus Booster ________________________

INSURANCE INFORMATION:

Insurance/Carrier Name __________________________________________________

Policy Number/Group Number _____________________________________________

Name of Primary person on Insurance ______________________________________

IN CASE OF EMERGENCY, CONTACT ME AT:

Home Phone_______________________ Work Phone ____________________

Cell Phone or Pager _____________________________

IN CASE OF EMERGENCY AND I CANNOT BE REACHED, PLEASE CONTACT:

Name___________________________________ Phone________________________

OR

Name___________________________________ Phone________________________

Page 2 of 2