Carmelite Sisters of the Most Sacred Heart of Los Angeles Décor Carmeli Volunteer Permission Form

General Information Date ______Girl’s Name: ______Mother’s Name: ______Mother’s Wk #: ______Father’s Name: ______Father’s Work #: ______Address: ______City/State/Z-Code: ______Home Phone #: ( ) ______Parent Cell #: ( ) ______Girl’s e-mail Address: ______Age: ____ D/O/B: ______Parent E-mail (to send information about volunteer days and other volunteer opportunities): ______Name of School: ______Grade Level: _____ Religion: ______Parish: ______Please Circle: First Communion: Yes No Confirmation: Yes No How did you find out about this program? ______Emergency Information Any known allergies? ______Any illness? ______Medications currently taking? ______Medications normally taken for headaches, stomach cramps, allergies, etc.? ______Insurance Company: ______Group Policy #: ______Family Doctor: ______Doctor’s Phone #: ______Emergency Phone Number: ______Cell #: ______Please list two additional adults who could be contacted in case of an emergency. Name: ______Relationship: ______Address: ______Home Number: ______Cell Number: ______Name: ______Relationship: ______Address: ______Home Number: ______Cell Number: ______

Décor Carmeli Application Form 2015-2016 (8-16-154) Page 1 Sacred Heart Retreat House Release Form

I request that my daughter, ______, be permitted to participate at the Sacred Heart Retreat House in the Décor Carmeli Volunteer Program. As a condition of being allowed to do so, I hereby, release and discharge the Retreat House from any and all claims for personal injuries or property damage that my daughter may suffer as a result of participation in the volunteer program listed above, whether or not such injuries or damages are caused by the negligence (active or passive) of the Retreat House and its employees. Should it be necessary for my daughter to have medical treatment while participating in the volunteer program, I hereby give the Retreat House permission to use their judgment in obtaining medical service, and I give permission to the physician selected by the Retreat House personnel to render medical treatment deemed necessary and appropriate by the physician. I agree to relieve the Retreat House and other participating adults from any liability in connection with this request.

______Parent/ Guardian Date

The Décor Carmeli volunteer days will begin at 8:15am and conclude at 5:30pm. It is requested that parents please be prompt in picking up their daughter. Consistent tardiness may have consequences in your daughter’s continued participation in the program.

If you are unable to pick up your daughter, please designate three other people to whom you give your permission and the authority to do so.

______Name Relationship Phone Number

______Name Relationship Phone Number

______Name Relationship Phone Number

Décor Carmeli Application Form 2015-2016 (8-16-154) Page 2 Sacred Heart Retreat House Permission for Use of Image and Likeness

I, ______understand and agree that from time to time, the facility and its sponsor, the Carmelite Sisters of the Most Sacred Heart of Los Angeles, in relation to their educational and apostolic work, may wish to publish photograph(s) or video containing the image of my daughter within informational/promotional media that may be available to the public. Said media may include but are not limited to brochures, visual/audio presentations, and websites. In addition, I further understand and agree that this authorization will remain in effect until it is withdrawn by the undersigned in a written notice.

I thereby agree and specifically grant permission to use image and likeness in the aforementioned Media.

I further hereby waiver, release and forever discharge any and all claims, demands or causes of action against the Sacred Heart Retreat House and the Carmelite Community and all its members, employees agents, and other persons, organizations or entities contracted by them, for damages or injuries in any way related to, connected to or arising from the publication of the aforementioned media.

Agreed to this ______day of ______, 20___

______First and last Name of Parent/Guardian (please print)

______Signature of Parent/Guardian

______Name of Minor e-mail of Parent/Guardian ______

Phone Number of Parent/Guardian: ______

Décor Carmeli Application Form 2015-2016 (8-16-154) Page 3