2024 Mission Trip Registration

Teen Participant Information

Teen Name

Teen Email

This address will receive a confirmation email

Teen Cell Phone

Landline Phone

Address

Gender

Male Female

Name of School

Grade (2021-2022)

Date of Birth

T-Shirt Size (all Adult sizes)

Small Medium Large X-Large XX-Large XXX-Large

Friend Request

Parent/Guardian 1 Information

P1 First Name

P1 Last Name

P1 Email

This address will receive a confirmation email

P1 Cell Phone

Parent/Guardian 2 or other Emergency Contact

P2 FirstName

P2 Last Name

P2 Email

This address will receive a confirmation email

P2 Cell Phone

Medical Information

DRUG & NON-FOOD allergies (describe allergy, reactions, seriousness & management).

FOOD allergies & dietary restrictions (describe allergy, reactions, seriousness & management)

Medical conditions, physical restrictions, learning challenges, behavioral conditions or social concerns

Medications

Medication Administration

Names of medications and exact dosage and frequencies/times:

No medication of any type whether prescription or nonprescription may be administered to this child unless the situation is life-threatening and emergency treatment is required.

True False - I give consent for over-the-counter medications EXCEPT for those listed in the next box.

Our Lady of Angels may provide non-prescription over-the-counter medications to the participant as needed, EXCEPT the following:

Note about Medications: All Medical Information will be maintained in a strictly confidential manner. Should your child have an Emergency Injection Device (Epi-Pen), Diabetic Condition, Asthmatics with a rescue inhaler, or other special medical conditions, a separate sheet will need to be attached with a clear description as to the nature of the medical condition and any medication. This is important for situations where the youth is not able to self-administer these treatments and to communicate with Emergency Personnel. Ministry leaders, volunteers, and other parish staff are NOT trained to administer these types of emergency medications.

Insurance Information

Insurance Company

Insurance Phone Number

Insurance Policy Number & ID

Name of Insurance Holder

Relationship of Holder to Teen

Permission to Travel

I, the parent or guardian of the child named above, grant permission for said child to participate in Catholic Mission Trips with Our Lady of Angels on June 15-22, 2024 in Hidalgo County, Tx. I understand that the mode of transportation will be via personal or rented vehicles holding no more than 8 people.

I grant permission for my child to participate in Catholic Mission Trips in Hidalgo County, TX as described on this form.

Consent to Participate and Liability Release

I / We, the parent(s)/guardian(s)/conservator(s) of the child listed on this form grant permission for my son/daughter to participate in all youth activities and functions. I understand that as parent/guardian/conservator, I remain legally responsible for any personal actions taken by my son/daughter. I/ We recognize the inherent risk associated with the various youth activities that my son/daughter will be participating in. I/ We agree on behalf of myself, my son/daughter named herein, my heirs, successors, and assigns to indemnify, defend, and hold harmless Our Lady of Angels Parish and the Roman Catholic Diocese of Dallas, their employees and/or volunteers from any and all claims (unless due to the Sole or Gross NEGLIGENCE of the Parish) for illness, injury, death, and the cost of medical treatment therewith, arising from or in any way connected with my son/daughter participating and/or attending the various youth programs and activities during this formation year noted above. In the event any legal action is taken by either party against the other party to enforce any of the terms and conditions of this release, it is agreed that the unsuccessful party to such action shall pay to the prevailing party therein all reasonable court costs, reasonable attorneys’ fees and expenses incurred by the prevailing party.

I have read this consent & liability release, & I understand & voluntarily agree to its provisions.

Authorization of Consent to Treat Minor

I/We, are the parent(s) &/or guardians of the child listed above, a minor, and as such do hereby authorize Our Lady of Angels, its youth ministry leaders, employees, contractors and volunteers as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician or surgeon licensed under the laws of the jurisdiction where such diagnosis or treatment may be given, whether such diagnosis or treatment is rendered at the office of said physician, at a hospital, or at any other location. It is understood that this authorization is given in advance of any specific treatment or diagnosis, but is given to provide authority and power of treatment, or hospital care which the aforementioned physician in the exercise of best judgment may deem advisable. This authorization is given pursuant to the provisions of Chapter 32 of the Texas Family Code. This authorization shall remain effective throughout the specific event dates listed on this form. In consideration of acceptance of this authorization, but without any time limitation and without any future right of revocation, I/we hereby release, defend and hold harmless the Parish and Roman Catholic Diocese of Dallas (Diocese), their officers, directors, agents, employees, volunteers, youth ministry leaders, and contractors from all claims, liabilities and loss in any way arising out of or in connection with or relating to such treatment and treatment decisions.

I have read this consent to treat statement, & I understand & voluntarily agree to its provisions.

Media Consent & Social Media Communications

On occasion, video recordings, audio recordings, photographic slides, and photographs are taken of children and youth during church and diocesan sponsored activities. These are utilized in newsletters, websites, event promotion, advertisements and other printed media. As the State of Texas does not prevent audio or video recording or the photographing of children/youth for good and valuable consideration, I hereby grant to Our Lady of Angels Catholic Church the irrevocable and unrestricted right to make, use and/or publish any and all photographs, videos, and other images of me/my minor child or images in which Student may be included, now existing or hereafter made, in any case, with or without identifying Student for editorial, advertising, news, or any other purpose and in any manner and medium; to alter the same without restriction; and to copyright the same. On behalf of myself and/or my child, I specifically waive all rights to privacy and confidentiality with respect to name, likeness, voice, photographs, images, video recordings, audio recordings and identifying information. I hereby release and agree to fully and unconditionally protect, indemnify, and defend Our Lady of Angels, the Roman Catholic Diocese of Dallas, and their respective officers, agents, and employees, (collectively, “Indemnitees”) and hold each Indemnitee harmless from and against any and all costs, expenses, attorney’s fees, claims damages, demands, suits, judgments, losses, or liability for injuries to property, injuries to persons (including Student) and from any other costs, expenses, attorney fees, claims, suits judgments, losses, or liabilities of any and every nature whatsoever arising in any manner, directly or indirectly, out of, in connection with, in the course of, or incidental to the use or publication of any photographs, videos, or other images of Student, REGARDLESS OF CAUSE OR OF THE JOINT, COMPARATIVE, OR CONCURRENT NEGLIGENCE OF THE INDEMNITEES. If you wish to opt out the participating child or discuss any part of this media release, please email Sheila Tullier at stullier@ourladyofangels.com.

I have read this consent for Media Release, & I understand and voluntarily agree to its provisions.

Participant Code of Conduct

Treat other participants, leaders, staff and residents with respect and understand that all adult leaders have the authority to discipline me. Follow the schedule and guidelines given to me. Alcohol, weapons, fireworks, tobacco products of any kind, illegal drugs and profane or abusive language are NOT ALLOWED on any part of this activity. (Prescription drugs must be dispensed by an adult leader.) Represent Our Lady of Angels Catholic Church and agree to behave in a Christian and positive manner at all times. Dress appropriately during all activities. Sexual indiscretion (including PDA’s-public displays of affection) is prohibited at all times and in all cases. No participant is allowed to leave without an adult’s permission. Stay with my assigned group at all times. Arrive no earlier than 15 minutes prior to scheduled start time of event and be picked up no later than 15 minutes after scheduled event conclusion. I, and my parents, will be financially responsible for any damage I do to others’ property, facilities or vehicles. If I choose to violate any part of this “code of conduct”, I may have my parents notified by phone and my parents may be asked to pick me up, immediately. **Participation by youth in video conferencing must take place form a common space in their home, not in their bedroom, e.g. living room, kitchen, patio – any place a parent could be close by or drop in.

I have read this Code of Conduct, agree to its provisions, & will review it with my child.

Electronic Signature for Agreements

Name of Person Giving above consents

Relationship to Participant

Electronic Signature of initials w/ Date of Birth, Last 4-Digits of Social Security Number or other unique ID

Payment Information

Contact Sheila Tullier, stullier@ourladyofangels.com, if you need balance due information on your teen.

Due Oct. 25: $130 (Deposit)
Due Nov. 25: $115 (Installment 1)
Due Jan. 25: $115 (Installment 2)
Due Feb. 25: $115 (Installment 3)
Due Mar. 25: $115 (Installment 4)

Total fee - $590

Payment

Would you like to donate?

As many of you know, our annual HS service trip has transformed the lives of many of our young people. Every year, our teens experience the living God by serving those who struggle to help themselves. If you would like to donate towards our transportation fund, we would GREATLY appreciate it!

Donation

Comments/Questions for YM Staff

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2024 Mission Trip Registration - TEENS

Description

2024 Mission Trip Registration - TEENS

Description

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