Winterblast 2019

Event: Winterblast 2019

Date of Event: Friday/Saturday, December 13-14, 2019

Destination: St. Vincent de Paul Catholic Church and Maple Grove Community Center

Individual(s)/Teacher(s) in Charge: Fr. Andrew Zipp, John Boyle

Drop off : SVDP at 7:30pm

Pick Up: Maple Grove Community Center at 5:30am

Mode of Transportation To Event: School Bus

Cost for event: $40

Participant Name (First and Last) REQUIRED Please fill out this field. Please enter valid data.

Sex REQUIRED Male Female Please fill out this field.

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

Date of Birth (MM/DD/YYYY) REQUIRED Please fill out this field. Please enter a date.

T-Shirt Size (Adult Sizes) REQUIRED Small Medium Large XL XXL XXXL Please fill out this field.

Parent/Guardian (First and Last) REQUIRED Please fill out this field. Please enter valid data.

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

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

WILL YOU HELP MAKE THIS EVENT POSSIBLE? YOU ARE NEEDED AS A CHAPERONE! Please enter valid data.

T-Shirt Size for Chaperone Please enter valid data.

I, (Parent/Guardian above), grant permission for (Participant Name above) to participate in the above named activity and I warrant that my child is in good health. In consideration of my child’s participation, I agree to indemnify St. Vincent de Paul Catholic Church, all Churches participating, and the Archdiocese of St. Paul & Minneapolis from any claims or law suits brought against St. Vincent de Paul Catholic Church , all Churches participating, and the Archdiocese of St. Paul & Minneapolis by myself, my child or others, that arises out of any behavior by my child at the event/activity described above. I also agree to pay reasonable attorney’s fees or expenses incurred by St. Vincent de Paul Catholic Church, all Churches participating, and the Archdiocese in defense of such a claim/suit. Should photos or video be taken, I give my permission for the use of my child’s image and /or likeness in any promotional or other marketing activities relating to the youth ministry programs of St. Vincent de Paul Catholic Church and all Churches participating.

I Agree Please select this field.

EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I give permission to transport my child to a hospital for medical treatment. I wish to be advised prior to any further treatment by a doctor or hospital. In the event of any emergency, if you are unable to reach me at the above numbers, contact

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

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

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

Optional Medical Information

Medication my child is taking at present Please enter valid data.

Family Health Plan Provider Please enter valid data.

Policy # Please enter valid data.

Family Doctor Please enter valid data.

Doctor's Phone Number Please enter a phone number.

As Parent or Guardian, I agree to all of the above stated considerations and conditions.

I Agree Please select this field.

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 .)

Medical Treatment: In the event it comes to the attention of St. Vincent de Paul Catholic Church or any of the other Churches participating, its officers, directors and agents, and the Archdiocese of Saint Paul & Minneapolis, chaperons, 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 called collect (with phone charges reversed to myself).

I Agree Please select this field.

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage, are indicated on attached sheet.

I Agree Please select this field.

I hereby grant permission for non-prescription medication (such as non-aspirin products, i.e. acetaminophen or ibuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.

I Agree Please select this field.

Specific Medical Information: St. Vincent de Paul Catholic Church and all Churches participating, will take reasonable care to see that the following information will be held in confidence.

Allergic reactions (medications, foods, plants, insects, etc.): Please enter valid data.

Immunizations-Date of last tetanus/diphtheria immunization: Please enter valid data.

Does child have a medically prescribed diet? Please enter valid data.

Any physical limitations? Please enter valid data.

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

Any special medical conditions?

Use of Image: I grant permission to St. Vincent de Paul Catholic Church to use and publish for advertising, commercial or publicity purposes, the name and likeness of my child, or for any other lawful purpose whatsoever, including photographic portraits, picture, reproductions, made through any medium, including electronic media and the undersigned parent/guardian does hereby release St. Vincent de Paul Catholic Church and all churches participating with such use. This authorization and consent permits such use to associate my child’s name with the likeness for such purposes provided such use and is consistent with the acceptable use policy for electronic communications and other policies.

I Agree Please select this field.

Electronic Communication: I authorize staff or other leaders of St. Vincent de Paul Catholic Church and parish leaders to communicate with my child electronically, including via social media in accordance with the Acceptable Use Policy for Electronic Communication.

I Agree Please select this field.

CODE OF CONDUCT

The following are a few rules that all participants are expected to follow while participating and representing St. Vincent de Paul Catholic Church and all Churches participating, in this event sponsored by St. Vincent de Paul Catholic Church, all Churches participating through December 13-14, 2019 Please read and agree.

I, (Participant Name above), WILL:

1. Treat all other persons with respect and not cause any intentional harm (physically, emotionally, or spiritually) to any person in any way.

2. Respect the property of others, including all program facilities and property.

3. Follow all appropriate instructions of all personnel aiding in this event, including, but not limited to, chaperones, support staff, transportation personnel and administration.

4. Be on time for all check-ins and departure time.

5. Not have in my possession any tobacco, alcohol or any controlled illegal substance

I agree that if any of these terms are violated St. Vincent de Paul Catholic Church can send the participant home at the participant/guardian’s expense.

I Agree Please select this field.

Cost40.0

Winterblast 2019

What is Winterblast?

LAST DAY TO REGISTER IS NOV. 10

REGISTRATION

Optional Medical Information

MEDICAL MATTERS

CODE OF CONDUCT