<p> SAYACTS © St. Luke ACTS Team Application Form and Parental/Guardian Consent Form and Liability Waiver</p><p>TEAM MEMBER INFORMATION: Name: ______First Name/Nickname on Badge:______</p><p>Address: ______City: ______Zip Code: ______</p><p>Teen Cell Phone______</p><p>Best form of communication: (circle one) Cell/Text/e-mail Teen E-mail: ______</p><p>High School (Fall 2014): ______Parish/Church: ______(name of school)</p><p>Shirt Size (circle): YL AS AM AL AXL A2XL Age:______xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx PARENT INFORMATION:</p><p>Parents/Guardian name: ______Home Phone: ______</p><p>Business Phone:______Cell Phone:______Parent E-Mail:______Volunteer in area of (circle one) : Send Off/Driver/Night Chaperon/Luggage</p><p>I, ______, grant permission for my child ______to participate in this youth ministry event requiring transportation to a location away from the parish site. This activity will take place under the guidance and direction of parish employees and/or volunteers from St. Luke Catholic Church. A brief description of the activity follows:</p><p> Type of Event: Teen ACTS Retreat  Date of the Event:______Place of Event: St. Mary’s University  Activities: Interaction with youth monitored by adults concerning religious, spiritual, moral, and social matters through prayer, scripture and personal sharing  Cost: $210.00 Deposit: $60.00 (Non-refundable) Payable to: St. Luke Youth ACTS  Estimated Time of Departure: ______at 6:30pm (from St. Luke Catholic Church)  Time of Return: ______at 4:00 Mass (at St. Luke Catholic Church)  Mode of Transportation to/from Event: Private Vehicles  For questions contact: Liz Ortiz, St. Luke Youth Minister @ 433-2777 ext. 119  Applications must be postmarked or submitted to church office by ______. As parent 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 Teen named herein, our heirs, successors and assigns to hold harmless and defend St. Luke Catholic Church, its officers, directors, and agents, and the Archdiocese of San Antonio from any and all liability for illness, injury or death arising from or in connection with my child’s personal actions at the above named event and I agree to compensate the parish, its officers and agents and the Archdiocese of San Antonio, or representative associated with the event for reasonable attorney’s fees and expenses arising in connection therewith.</p><p>Signature of Parent/Guardian: ______Date: ______Drop off or mail to St. Luke Catholic Church, 4603 Manitou, S.A., TX 78228 </p><p>SAYACTS © MEDICAL CONSENT AND PERMISSION TO TREAT</p><p>************** Please include a photocopy of your Insurance Card (front and back) ******************</p><p>To the best of my knowledge, my child, ______, is in good health, and I assume all responsibility for the health of my child.</p><p>Emergency Medical Treatment: In the event of an emergency, I hereby grant permission to transport my child to a hospital for emergency treatment _____ Yes _____ No</p><p>I wish to be advised prior to any further treatment by the hospital or doctor ____ Yes ____ No</p><p>Parent/Guardian: ______Home Address: ______Home Phone: ( ) ______Cell Phone: ( ) ______Business Phone: ( ) ______If you are unable to reach me, please contact:</p><p>Name: ______Relationship to me or my Child: ______Home Phone: ( ) ______Cell Phone: ( ) ______Business Phone: ( ) ______</p><p>Family Doctor: ______Phone Number: ( ) ______</p><p>Insurance Carrier: ______Policy Number: ______************** Please include a photocopy of your Insurance Card (front and back) ******************</p><p>My child is taking medication and will bring all medication with him/her to the retreat. It will be clearly labeled. My child is taking the following medication(s) and directions for taking this medication, including dosage, frequency and storage is as follows: ______.</p><p>I hereby grant permission for non-prescription medication (such as cough drops, cough syrup, Tylenol, etc.) to be given to my child if necessary: ____ Yes ____ No</p><p>I understand that aspirin will not be given to my child without me expressed permission. I hereby grant such permission: ____ Yes ____ No</p><p>My child is allergic to the following (medications, foods, plants, insects, etc.) ______</p><p>My child’s immunization record is current and up to date: ____ Yes ____No My child’s last tetanus shot was ______My child has the following physical limitation ______My child experiences: homesickness emotional reactions to new situations sleepwalking fainting other: ______Yes ____ No My child has recently been exposed to a contagious disease or condition such as mumps, measles, chickenpox, etc. ______Yes ____ No If Yes, please state the disease and date or condition: ______</p><p>My child is suffering from a psychological condition, which may affect or limit his or her ability to participate in this activity. ____ Yes ____ No If Yes, please explain:______</p><p>Signature of Parent or Guardian: ______Date: ______</p><p>Drop off or mail to St. Luke Catholic Church, 4603 Manitou, S.A., TX 78228 </p>