Parish: Our Lady of Mount Carmel Phone:
595-0385x128
Address: 100 Harpersville Road City:
Newport News Zip: 23601
Type of Event: retreat for Year 2 Confirmation Candidates
Destination: Makemie Woods Retreat Center, west of Williamsburg
Individual in Charge: Angela Hamrick
Place of Departure: OLMC Estimated Time of
Departure: 5:30pm
Dates of Trip: Jan 7-9, 2005 Estimated Time of
Return: 12:30 pm
Mode of Transportation to and from the event: bus
Participant's Name___________________________________________________
Sex Date of Birth Age__________________________
Parent/Guardian's Names______________________________________________
Home Address____________________________________________________
City State Zip___________________
Home Phone Work Phone_______________________
Number parent/guardian can be reached on date of event_____________________________
Emergency Contact Person Phone___________________
Relationship to participant_____________________________________________________
I (parent,/guardian above) grant permission for my child participant above) to participate
in this parish youth ministry even that requires transportation to a location away from the parish
site. This activity will take place under the guidance and direction of the parish employees and/or
volunteers. A brief description of the activity is give at the top of the page.
As parent and/or legal guardian, I remain legally responsible for any personal actions taken
by my child. I agree on behalf of myself, my child name herein, or our heirs, successors, and
assigns, to hold harmless and defend this Parish (listed above), its officers, directors, and
agents, and the Diocese of Richmond, Virginia, chaperones, or representatives associated with
this event, arising from or in connection with my child attending the event or in connection with
any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate
the parish, its officers, directors and agents, and the Diocese of Richmond, chaperones, or
representatives associated with the event for reasonable attorney's fee and expenses arising in connection there within.
Signature Date
(Note: Does the youth minister have a copy of your medical release form on file? (You
filled one out if you registered for RE this year). If not, make sure you get one filled out before the trip.