Summer Mission Trip

Parents, please fill out this form and check the boxes to show that you have read and agree to the conditions therein.

I hereby give permission for my son/daughter, named below, to participate in the Mission Trip Retreat in Indianapolis, IN being led by the Alive in You organzation. Please select this field.

I understand that transportation to this event will be provided by an adult driving a van/car from St. John's to the camp in Indianapolis, IN. Please select this field.

I hereby release and indemnify St. John the Evangelist Catholic Parish, its staff and its volunteers, as well as the Catholic Bishop of Chicago, a corporate sole, from any and all liability arising from claims of any kind or nature whatsoever. Please select this field.

I also understand that my child will be under supervision and that all adult leaders from the Parish will be in full compliance with the requirements and policies of the Archdiocese of Chicago's Office for the Protection of Children and Youth. Please select this field.

I understand that if my child violates any laws regarding possession of alcohol or drugs, or rules governing the event, I will be expected to retrieve my son or daughter from the event as soon as possible. Please select this field.

I grant permission for the adult chaperones for this event to administer non-prescription drugs as needed for my teen (i.e. aspirin, ibuprophen, antacids, etc.) Please select this field.

I authorize St. John the Evangelist Catholic Church and the Archdiocese of Chicago to use photographs/videos of my teen for productions, publications, website, and Facebook, Twitter, or Instagram. Please select this field.

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

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

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

Street Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

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

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

List any allergies, medications, medical issues, physical activity limitations that your teen cannot take part in AND/OR any other important information. Please enter valid data.

Current Medications Please enter valid data.

Name of Physician REQUIRED Please fill out this field. Please enter valid data.

Physician Phone Number REQUIRED Please fill out this field. Please enter valid data.

Insurance Policy in the name of REQUIRED Please fill out this field. Please enter valid data.

Insurance Company REQUIRED Please fill out this field. Please enter valid data.

Policy Number REQUIRED Please fill out this field. Please enter valid data.

Identification Number REQUIRED Please fill out this field. Please enter valid data.

T-shirt Size REQUIRED Small Medium Large Extra Large Please fill out this field.

Other

Registration Fee100.0

St. John the Evangelist
Catholic Parish and School

Streamwood, IL

Summer Mission Trip

Registration for Summer Mission Trip