BE COURAGEOUS
Our Lady Queen of Heaven
Parish Middle School Day Retreat
6th, 7th and 8th grade students
Our Lady Queen of Heaven Family Life Center
Lake Charles, LA
Saturday, July 11, 2015 10 am to 5:15pm
Registration Deadline: July 2, 2015
Please print all information clearly
Name: ____________________________________________________
Mailing Address: ____________________________________________
City: __________________________ Zip Code: _________
Parent’s e-mail address: ______________________________________
Preferred Parent Contact:
Name: __________________________ phone/cell # __________
Registered Church Parish: ____________________________________
School Name:______________________________________________
Circle one of each below:
Grade: 6 or 7 or 8 Gender: m or f T-Shirt Size: ____ (youth or adult size)
Cost of Retreat = $20 (includes lunch and t-shirt) (make payable Our Lady Queen of Heaven)
MEDICAL: I hereby warrant that to the best of my knowledge, my child is in good health and I assume all
responsibility for the health of my child. In the event of an emergency, I hereby give my permission to transport
my child to a hospital for emergency or surgical treatment. I wish to be advised prior to any further treatment
by the hospital or doctor.
In the event of an emergency, if you are unable to reach me at the above numbers, contact:
Emergency Contact: _________________________ phone/cell # _______________________
Page 1 of 2
Family Health Plan Carrier: ____________________ Policy/plan Number: ________________
Participant’s Doctor Name: __________________________ Phone Number ________________
CONTRACT OF BEHAVIOR
1) Taking care of the property of Our Lady Queen of Heaven Family Life Center and paying for any
accidental damage to property.
2) All people – participants, adults, speakers, and diocesan staff are to be treated with respect by everyone
else.
3) Maintaining a healthy environment – no mood altering drugs, including alcohol, is to be used by anyone
including adults. Prudent precaution will be taken to assure that no one has any mood altering drugs in
their possession. Possession of alcohol is grounds for dismissal from the retreat. We provide a smokefree environment.
4) Maintaining a moral atmosphere – At all times dress, music, dance, language, signs of affection, tone of
voice is to be appropriate.
I have read the above responsibilities of participants and as a participant will abide the code of behavior found
therein.
PHOTO/VIDEO RELEASE FORM
I hereby give permission for images of my child, captured at Our Lady Queen of Heaven Catholic Church
Ministry events through video, photo and digital camera, to be used solely for the purpose of Our Lady Queen
of Heaven Catholic Church promotional material and publications, and waive any rights of compensation or
ownership thereto. I hereby waiver any right that I or the Minor may have to inspect or approve the finished
product or products and the advertising copy or other matter that may be used in connection therewith or the
use to which it may be applied.
If you would like your child to participate in this event, please complete, sign and return this form after having
read and agreeing to the following statement of consent and release of liability. As a parent or legal guardian,
you remain fully responsible for any legal responsibility which may result from any personal actions taken by
the below named student. Any student failing to produce this signed permission slip by the date of the event
will not be allowed to attend this event.
I hereby request that my child, (Name of Child) ______________________________________, be allowed by
Our Lady Queen of Heaven to participate in the event described above. I consent to the conditions stated
above on participation in this event and I release the Diocese of Lake Charles, Our Lady Queen of Heaven Parish,
the school/parish and all diocesan and school/parish personnel from any and all liability claims that may result
from this event in case of accident or injury to my child.
I HAVE CAREGULLY READ THIS AGREEMENT AND FULLY UNDERSTAND its CONTENTS. I AM AWARE THAT THIS IS
A RELEASE OF LIABILITY AND SIGN IT OF MY OWN FREE WILL.
Printed Name of Parent/Guardian: _______________________________________________
Parent/Guardian’s Signature: ___________________________________________________
Date: ________________________________________
Page 2 of 2