October 12 – Senior Retreat; St. Monica Catholic Church
October 13 – Middle School Retreat (6th -8th grades); St. Margaret Mary Parish Activity Center
October 14 – 9th -11th Grades Retreat; St. Francis Xavier Parish Center

 Fax, mail or drop of at your parish office to:

Catherine Wharton
St. Francis Xavier Parish
525 Market Street
Parkersburg, WV  26101
phone:  304.422.6786   fax: 304.422.6789


Participant’s Name:  ____________________________________________________________

 Birth Date: ____________________ Gender: ______  Grade: _______School:_______________

 Parent/Guardian’s Name_________________________________________________________

 Home Address: ________________________________________________________________

 Home Phone: _______________Cell Phone (parent):________________Email (parent)__________

 I, ______________________________, grant permission for my child, ____________________
           Parent or Guardian’s Name                                                                  Child’s Name

to participate in this youth event.

Type of Event: N.E.T. Retreat

As parent/and or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (participant).

I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St. Francis Xavier Parish, St. Margaret Mary Parish, St. Monica Parish,  their officers, directors and agents, and the Diocese of Wheeling-Charleston, chaperons, or representatives associated with the event, arising from or in connection with my child attending the event or in connection with any illnesses or injury or cost of medical treatment in connection therewith, and I agree to compensate the parishes, their officers, directors and agents, and the Dioceses of Wheeling-Charleston, chaperons, or representative associated with the event for reasonable attorney’s fees and expenses arising in  connection therewith.

Signature: _________________________________________        Date: ______________________________

  Medical Matters:  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.  (Of the following statements pertaining to medical matters, sign only those that are applicable.)

 Emergency Medical Treatment:  In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical 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:

 Name and Relationship:  ______________________________________ Phone: _____________________

 Family Doctor: ______________________________________________ Phone: _____________________

 Family Health Plan Carrier: ____________________________________ Policy #_____________________

 Signature:___________________________________________________ Date: _______________________

  Other Medical Treatment: In the event it comes to the attention of St. Francis Xavier, St. Margaret Mary, St. Monica or St. Mary parishes, their officers, directors and agents, and/or the Dioceses of Wheeling-Charleston or of Steubenville, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be contacted.

 Signature: _______________________________________________         Date:  ___________________

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

 Signature: _______________________________________________         Date:  ___________________

 I hereby grant permission to non-prescription medications such as (aspirin, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.

 Signature: _______________________________________________         Date:  ___________________

 _________________________________________________________ _

Specific Medical Information: The Parishes will take reasonable care to see that the following information be held in confidence.

Allergic reactions (medications, foods, plants, insects, etc.): ____________________________________

Immunizations: Date of last tetanus/diphtheria immunization: ___________________________________

Does child need special accommodations (please specify)?  ____________________________________


Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc.? If so, date, disease or condition: ____________________________________________

You should be aware of these special medical conditions of my child: