CHRISTMAS RETREAT 2004

INFORMATION AND CONSENT FORM
(please print and fill in appropriate sections)

Name:

Allergies, special diet needs or other conditions:

Medication:

Health insurance carrier:

          Group number:

          Policy number:

Name and phone of primary care physician:

PARENTAL RELEASE
(for participants under 18 years of age)

I,  [parent name]

am the parent or legal guardian of  [participant name]        

I hereby release St Vladimir’s Seminary and its agents and employees from any and all liability for all personal injuries known or unknown that the youth named above may incur due to reasons unrelated but not limited to negligence by participating in activities conducted, sponsored, or associated with the Christmas Retreat.

In the event of an emergency, I, or my spouse, may be reached at the following telephone numbers:

#1:   

#2:

Also, in the event that I cannot be reached in the case of emergency, I do hereby authorize a physician selected by the coordinator of this event to administer emergency medical treatment including medications, diagnostic tests, surgery or other medical intervention deemed necessary by the physician.

I, the undersigned, have read this release and understand all its terms.  I execute it voluntarily on behalf of myself and the participant named above and with full knowledge of the significance to bind all persons.  In witness thereof, I have signed this release on the date indicated below.

Name:

Relationship:

Signature:           

Date: