2019 YOUTH Fall Retreat Registration

Teen Information
Teen Name *
Teen Name
Teen Address *
Teen Address
Parent / Guardian Information
Mother's Name *
Mother's Name
Phone Number *
Phone Number
Address *
Address
(If Different from Teen)
Father's Name *
Father's Name
Phone Number *
Phone Number
Address *
Address
Emergency Contact Information
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone Number *
Emergency Contact Phone Number
Medical Information
Phone Number of Physician's Office *
Phone Number of Physician's Office
(Please list all food and medicinal allergies)
(Please list any prescription medications your teen is currently taking)
Over the Counter Medication *
Please check the box for any OTC medication that you will allow Sacred Heart to administer to your teen should there be a need for treatment
I hereby grant permission for Sacred Heart Catholic Church to use the image and likeness of my child during the fall retreat. I acknowledge that this image and likeness may be used for, but not limited to: parish website, social media, photo/video/promotional materials for Life Teen, Sacred Heart Catholic Church and its ministries and programs during this event.
Today's Date *
Today's Date