St. Matthew School Confirmation Retreat

Student name REQUIRED Please fill out this field. Please enter valid data.

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

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

Parent/Guardian Cell Phone (for primary emergency contact) REQUIRED Please fill out this field. Please enter valid data.

Permission
The above named hereby states that he/she is the parent or legal guardian of the Student Participant and has full legal responsibility for the Student Participant. The above named hereby grants permission for the Student Participant to participate in the St. Matthew Confirmation Retreat.

Please select one: REQUIRED This student has my permission to participate. This student does NOT have my permission to participate. Please fill out this field.

Medical Information

Current medical conditions, including allergies, dietary restrictions, or physical limitations: REQUIRED Please fill out this field.
Current Medication: If the participant is taking medication at present, the participant will bring all such medications necessary, and such medications will be well-labeled. Please note names of medications and concise directions for taking such medications, including dosage and frequency of dosage. If the student is not taking any medication, please type "none."
Medication names and instructions REQUIRED Please fill out this field.
Non-prescription medication (please select one): REQUIRED No medication of any type, whether prescription or non-prescription, may be administered to the participant unless the situation is life-threatening and emergency treatment is required. Non-prescription medication may be given to the participant, if deemed appropriate. Please fill out this field.
Emergency Medical Treatment: In the event of an emergency, the above named parent/guardian hereby give(s) permission to transport the participant to a hospital for emergency medical or surgical treatment. The above named wish(es) to be advised prior to any further treatment by the hospital or doctor.
In the event of an emergency, if the above named cannot be reached at the above number, contact the following (Name, Relationship, Phone Number): REQUIRED Please fill out this field.

Release and Indemnification

Release: The above named on behalf of the above named, the Student Participant, and the heirs, successors and assigns of the above named and the Student Participant, hereby release, hold harmless from any liability, and discharge from all direct or derivative claims, actions, causes of actions, medical expenses, costs, legal expenses, other expenses and all other damages at law or in equity, known or unknown, direct or indirect, choate or inchoate against the Diocese of Columbus, the Parish and all current and former employees, agents, clergy, officers and volunteers of the Diocese of the Parish, arising from the Participant’s participation in the Activity named above.
I agree: REQUIRED Yes No Please fill out this field.
Indemnification: The undersigned shall indemnify and hold harmless the Diocese of Columbus, the Parish, and all current and former employees, agents, clergy, officers and volunteers of the Diocese of Columbus or the Parish from any claim, liability, suit, judgment, loss, damage, expense, fee or cost (including court costs and attorney fees) arising directly or indirectly from the Participant’s participation in the Activity named above, unless arising from the negligence of an indemnified party.
I agree: REQUIRED Yes No Please fill out this field.

Coronavirus Acknowledgement & Waiver: I agree, represent and warrant that neither the undersigned, nor any registered participant child(ren) shall visit or participate in the Confirmation Retreat within 14 days after (1) returning from outside the United States or areas within the United States designated as hot spots as determined by the CDC and the State of Ohio, (2) exposure to any person returning from outside the United States, or areas within the United States designated as hot spots as determined by the CDC and the State of Ohio, (3) exposure to any person who has a suspected or confirmed case of COVID-19; OR if he or she (1) experiences symptoms of COVID-19, including without limitation, fever, cough or shortness of breath, or (2) has a suspected or diagnosed/confirmed case of COVID-19. The undersigned agrees to notify Maggie Smith (msmith@stmatthew.net) immediately if any of the foregoing access/use restrictions may apply. The aforegoing does not apply to any parent who is employed in health care settings and wear medically protective equipment. St. Matthew Youth Ministry and St. Matthew have, or may put in place, preventative measures to reduce the spread of COVID-19. I agree to comply with measures that may be required to best protect against the introduction of viruses at the parishes, including, but not limited to hygiene practices and temperature screening, completion of a daily screening form, social distancing, and the use of personal protective equipment such as masks and/or gloves. However, St. Matthew Youth Ministry and St. Matthew cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending the Confirmation Retreat may or may not increase your risk and your child(ren)’s risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I could possibly be exposed to or infected by COVID-19, by participating in the Confirmation Retreat and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Confirmation Retreat and/or St. Matthew may result from the actions, omissions, or negligence of myself and others, including but not limited to, employees and volunteers of St. Matthew Youth Ministry, or participating parishes, in addition to other program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself, including but not limited to, personal injury, disability, death, illness, damage, loss, claim, liability or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the Confirmation Retreat. On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge and hold harmless Bishop Robert Brennan, the Diocese of Columbus, St. Matthew Youth Ministry, all participating Catholic diocesan parishes, schools and their employees, volunteers, agents, and representatives of and from any and all claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of any of the foregoing persons or entities, its employees, volunteers, agents, and representatives, whether a COVID-19 infection occurs before, during or after participation in the Confirmation Retreat or any activity.

Do you agree? REQUIRED Yes No Please fill out this field.

Code of Behavior:

The Participant shall comply with the following:

The Participant must stay and participate in the entire event.
The Participant may not leave the premises unless accompanied by an adult leader, parent, or legal guardian.
The possession or use of alcohol, tobacco, drugs, or weapons of any kind is not permitted.
Foul language is not tolerated.
The Participant must comply with any and all directions of activity staff.
The Participant must respect the rights and property of others.
Damage to or defacing of property will be the financial responsibility of
The Participant involved and the undersigned.
Failure to abide by this Code of Behavior may result in a request to the undersigned to transport the offending Participant from the premises, and the undersigned shall immediately comply with the request.

By typing his or her name, both the Participating Student and the Parent/Guardian agree to and accept all provisions in this registration form and agreement.

Student Name and Date REQUIRED Please fill out this field. Please enter valid data.

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