Regnum Christi Ohio Valley - ECYD Girls Grades 7-8 Retreat - St Agnes

1. Child's First and Last Name REQUIRED Please fill out this field. Please enter valid data.

Child's Birthdate REQUIRED Please fill out this field. Please enter a date.

Child's Grade in School REQUIRED Please fill out this field. Please enter valid data.

2. NATURE AND DURATION OF ACTIVITIES: 7th/8th Grade Retreat January 28-30, 2022 at Our Lady of the Holy Spirit Center, 5440 Moeller Ave, Norwood, OH 45212. Activities will include prayer experiences, small group discussions, team building activities and talks.

3. ACTIVITY SUPERVISOR(S): Rachel Peach, Jacquie Lustig and other adult chaperones and young adult team leaders.

4. TRANSPORTATION : Not Applicable. Participants are responsible for securing their own transportation to and from activities, as the company does not provide transportation.

5. MENTORING: Participants may be offered mentoring, which is intended to help young people personalize the principles of Christian living that they receive at home and in club activities. Mentoring involves a one-on-one conversation with an adult conducted in plain view of others. When dealing with adolescents, confidentiality will be maintained to foster openness of dialogue, but situations involving sexual abuse of a minor or threats to life or physical health will be reported to the appropriate authority and to the parents (except in those cases where the parent may be the alleged abuser).

6. REQUIREMENTS: The child named above is in good health and has no physical or medical limitations that would cause the activities as described above to be detrimental or dangerous to the child. Parents/guardians should specify allergies and medical problems in section 10 below.

7. CONSENT: I/We hereby consent to the above-named child's participation in the activities described above including mentoring, and specifically request that he be allowed to participate in those activities. I/We warrant that I/We have full authority to legally consent to her participation in the activities described on this form, and all provisions contained herein.

8. AUTHORIZATION: I/We hereby authorize RC Activities, Inc. to use the image and likeness of my/our child in photograph or video form whether taken by or commissioned by RC Activities, Inc. in its promotional materials and for its promotional purposes associated with its nonprofit activities. This authorization shall extend to use of my/our child’s image and likeness on the website of RC Activities, Inc., or its successor in operation or affiliated organization(s) upon written consent of RC Activities, Inc. I/We understand that this authorization shall survive the end of my/our child’s participation in the activities referenced on this form.

9. INSURANCE: I/We understand that RC Activities, Inc. does not carry any health insurance relative to the activities or for any injury that may occur to the above-named child. I/We represent that the child is (a) covered by insurance through my/our own insurance carrier; or (b) that I/We am/are personally financially responsible for any and all medical costs incurred as a result of the child's injury.

10. EMERGENCIES : If the above-named child requires any emergency medical procedures or treatments during the activities, I/We consent to the activity supervisor(s) taking, arranging for or consenting to such procedures or treatments in the discretion of the activity supervisor(s). For purposes of such procedures and treatments, my/our child's blood type allergies or other medical problems (if any) are listed below:

Blood Type: Please enter valid data.

Allergies / Medical Problems: Please enter valid data.

Participant's current Medications: Please enter valid data.

Does participant have any behavioral, psychological or medical situations to be aware of? REQUIRED Yes No Please fill out this field.

If yes, what types of accommodations would she need over the retreat weekend, if any? A member our pastoral team will be in touch with you. Please enter valid data.

11. EMERGENCY CONTACTS: If, in the event of a medical or other emergency, I/We am/are unable to be reached by telephone at the numbers listed below, I/We authorize the activity supervisor(s) to attempt to contact me/us through the alternative emergency contacts listed below.

Parents/ Guardians Contact Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Street 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.

Email REQUIRED Please fill out this field. Please enter an email address.

Cell Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Alternate Phone Number Please enter a phone number.

Alternative Emergency Contact Information

Name Please enter valid data.

Relation Please enter valid data.

Cell Phone Number Please enter a phone number.

Alternate Phone Number Please enter a phone number.

Name 2 Please enter valid data.

Relation Please enter valid data.

Cell Phone Number Please enter a phone number.

Alternate Phone Number Please enter a phone number.

12. I give permission for Event Supervisor(s) and Club Leader(s) to communicate with my child using text messaging and/or email regarding the details of the Activity / Program (Only participants 15 years old and older). REQUIRED Yes, I give permission for my child to be contacted. No, I do not wish to have my child contacted. Please fill out this field.

Child's Email Please enter an email address.

Child's Phone Number Please enter a phone number.

I would like to be copied on all emails and text messages to my child. Yes No

Parent's Email Please enter an email address.

Parent's Phone Number Please enter a phone number.

13. RELEASE AND INDEMNIFICATION: I/We release and waive, and further agree to indemnify, hold harmless or reimburse RC Activities, Inc. and Consolidated Catholic Administrative Services, Inc., the individual members, agents, directors, officers, employees, volunteers and representatives thereof, as well as activity supervisors, from and against, any claim which I, any other parent or guardian, any sibling, the above-named child, or any other person, firm or corporation may have or claim to have, known or unknown, directly or indirectly, for any losses (including attorneys’ fees incurred by RC Activities, Inc. and Consolidated Catholic Administrative Services, Inc., or any of its individual employees, agents, volunteers, etc. in enforcing this indemnity provision) without limitation in time or amount, damages or injuries arising out of, during, or in connection with my/our child's participation in the activities, the travel to and there from, and the rendering of emergency medical procedures or treatment, if any. I/We understand that this release and indemnification shall survive the end of my/our child’s participation in the activities referenced on this form and shall have no limitation in time or amount.

ASSUMPTION OF COVID-19 RISK AND WAIVER OF LIABILITY

I acknowledge [for myself and/or my child(ren)] the highly contagious nature of COVID-19, as well as its potential to cause infection, illness, injury, permanent disability, and death. I voluntarily accept and assume the risk that I may be exposed to or infected by COVID-19 by visiting/participating/attending the above named event operated by RC Activities, Inc. I further accept [for myself and/or my child(ren)] and assume the risk that such exposure or infection may result in my [my child(ren)] personal injury, illness, permanent disability, and/or death. RC Activities, Inc. cannot prevent you [for yourself and/or your child(ren)] from becoming exposed to, contracting, or spreading COVID-19 while visiting/participating/attending the above named event It is not possible to prevent against the presence of the disease. Therefore, if you [for yourself and/or your child(ren)] choose to visit/participate/attend the above named event you [for yourself and/or your child(ren) may be exposing yourself [your child(ren)] to and/or increasing your risk of contracting or spreading COVID-19.

I understand that the risk of becoming exposed to or infected by COVID-19 may be increased as a result of the actions, omissions, and/or negligence of RC Activities, Inc., including its independent contractors, agents, vendors, guests, and employees. I voluntarily assume [for myself and or my child(ren)] all of the risks of COVID-19 and of COVID-19 exposure and accept sole responsibility for any harm to me [my child(ren)] (including, but not limited to, personal injury, illness, permanent disability, and death).

In consideration of RC Activities, Inc. allowing me onto its premises/visiting/participating/attending the above named event I also, on behalf of myself [my child(ren)] and my successors and representatives, waive, release, and forever discharge RC ACtivities, Inc. , its agents, employees, officers, directors, contractors, customers, successors, and assigns from any and all claims and causes of action of any kind or nature which are in any way related, directly or indirectly, to COVID-19, which I may have or that hereafter may accrue, including any such claims or causes of action caused in whole or in part by the negligence of RC Activities, Inc., its agents, employees, officers, directors, contractors, customers, successors, and assigns. I [for myself and/or my child(ren)]further agree that I will not bring any claim or cause of action against RC Activities, Inc., its agents, employees, officers, directors, contractors, customers, successors, and assigns related in any way, directly or indirectly, to COVID-19, and/or any associated personal injuries, illness, disability, or death.

I [for myself and/or my child(ren)]further agree to indemnify, defend, and hold harmless RC Activities, Inc., its agents, employees, officers, directors, contractors, customers, successors, and assigns from any claims or causes of action of any kind arising from my exposure to COVID-19 as a result of visiting/participating/attending the above named event provided by RC Activities, Inc.

Yes - I/We have read and understand the above and agree to all terms and conditions contained therein. Please select this field.

Date REQUIRED Please fill out this field. Please enter a date.

Parent 1 Name REQUIRED Please fill out this field. Please enter valid data.

Parent 2 Name Please enter valid data.

Would Mom be interested in helping in the kitchen during the weekend? REQUIRED Yes No Please fill out this field.

*RC Activities reserves the right to deny acceptance to any applicant at any point in this process.

NOTE: Cancellations will receive a refund for the amount paid less $15 for 5th/6th graders or $10 for high school leaders to cover our bank fees and processing costs.

Registration Options REQUIRED 150.0 – Girls Retreat Fee 85.0 – High School Team Leaders Fee 0.0 – Transfer December Retreat Registration Please fill out this field.

Optional Additional Donation

Your additional donation is appreciated to support the ministry of our LC priests and Consecrated Women of Regnum Christi, who are running this retreat. Thank you!
Additional Donation $ Please enter a positive decimal.

ECYD Girls Grades 7-8 Retreat - St Agnes

Retreat Details

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ASSUMPTION OF COVID-19 RISK AND WAIVER OF LIABILITY