CATHOLIC HEART WORK CAMP RELEASE Forms

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  2026 Catholic Heart Work Camp Registration and Release Form
  
  Family Information
  
  Primary Parent/Guardian
  
  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.
  
  Primary Parent Email REQUIRED Please fill out this field. Please enter an email address.
  
  Street Address REQUIRED Please fill out this field. Please enter valid data.
  
  City Please enter valid data.
  
  State
  
  Zip Please enter a zip code.
  
  Secondary Parent/Guardian
  
  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.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Street Address (If different from Primary) Please enter valid data.
  
  City Please enter valid data.
  
  State
  
  Zip Please enter a zip code.
  
  EMERGENCY CONTACT :
  To be called if primary and secondary parent/guardian can not be reached
  
  Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Minor: REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED
  
  Please fill out this field. Please enter a phone number.
  
  Number of Children being registered Please fill out this field.
  
  Child Info 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Address if different from Primary Parent Please enter valid data.
  
  T-shirt Size (District Perfect Weight Tee DT 104L (ladies), DT 104 (unisex)) REQUIRED Please fill out this field.
  
  Food Allergies, Medication Allergies, Food Sensitivities/Intollerance REQUIRED Please fill out this field. Please enter valid data.
  
  Medications*- Rx, OTC, Vitamins / Glasses or Contacts / Other Pertinent Comments REQUIRED Please fill out this field. Please enter valid data.
  
  *All medication (prescription and over-the-counter) to be taken by your child during this event must be turned into the parish representative, along with THIS form, prior to departure, with full instructions as indicated on form. All medication must be in original packaging or in packaging provided by the pharmacy or doctor with instructions for administering the medication.
  I Agree Please select this field.
  
  The youth ministry's first aid kit contains common OTC Medications often taken "as needed". While we do not guarantee availability, are there any medicines you give us permission for us to provide to your child upon their request?
  
  By electronically signing below, you are hereby giving the parish team permission to dispense the selected medication(s) as directed on the packaging. REQUIRED ***NONE*** Aspirin Acetaminophen (Tylenol) Ibuprofen (Motrin/Advil) Naproxen Sodium (Aleve) Diphenhydramine HCL (Benadryl) Cough Drops Sunscreen Bug Repellent Please fill out this field.
  
  By entering into and/or signing this document, the signatory/signatories agree to conduct its/their dealings via electronic means. The signatory agrees that allowing dealings via electronic means will facilitate these dealings. The signatory has the option to opt to sign things in a paper format.
  I Agree Please select this field.
  
  Signature: (Parent/Guardian REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  Child Info 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Address if different from Primary Parent Please enter valid data.
  
  T-shirt Size (District Perfect Weight Tee DT 104L (ladies), DT 104 (unisex)) REQUIRED Please fill out this field.
  
  Food Allergies, Medication Allergies, Food Sensitivities/Intollerance REQUIRED Please fill out this field. Please enter valid data.
  
  Medications*- Rx, OTC, Vitamins / Glasses or Contacts / Other Pertinent Comments REQUIRED Please fill out this field. Please enter valid data.
  
  *All medication (prescription and over-the-counter) to be taken by your child during this event must be turned into the parish representative, along with THIS form, prior to departure, with full instructions as indicated on form. All medication must be in original packaging or in packaging provided by the pharmacy or doctor with instructions for administering the medication.
  I Agree Please select this field.
  
  The youth ministry's first aid kit contains common OTC Medications often taken "as needed". While we do not guarantee availability, are there any medicines you give us permission for us to provide to your child upon their request?
  
  By electronically signing below, you are hereby giving the parish team permission to dispense the selected medication(s) as directed on the packaging. REQUIRED ***NONE*** Aspirin Acetaminophen (Tylenol) Ibuprofen (Motrin/Advil) Naproxen Sodium (Aleve) Diphenhydramine HCL (Benadryl) Cough Drops Sunscreen Bug Repellent Please fill out this field.
  
  By entering into and/or signing this document, the signatory/signatories agree to conduct its/their dealings via electronic means. The signatory agrees that allowing dealings via electronic means will facilitate these dealings. The signatory has the option to opt to sign things in a paper format.
  I Agree Please select this field.
  
  Signature: (Parent/Guardian REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  Child Info 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Address if different from Primary Parent Please enter valid data.
  
  T-shirt Size (District Perfect Weight Tee DT 104L (ladies), DT 104 (unisex)) REQUIRED Please fill out this field.
  
  Food Allergies, Medication Allergies, Food Sensitivities/Intollerance REQUIRED Please fill out this field. Please enter valid data.
  
  Medications*- Rx, OTC, Vitamins / Glasses or Contacts / Other Pertinent Comments REQUIRED Please fill out this field. Please enter valid data.
  
  *All medication (prescription and over-the-counter) to be taken by your child during this event must be turned into the parish representative, along with THIS form, prior to departure, with full instructions as indicated on form. All medication must be in original packaging or in packaging provided by the pharmacy or doctor with instructions for administering the medication.
  I Agree Please select this field.
  
  The youth ministry's first aid kit contains common OTC Medications often taken "as needed". While we do not guarantee availability, are there any medicines you give us permission for us to provide to your child upon their request?
  
  By electronically signing below, you are hereby giving the parish team permission to dispense the selected medication(s) as directed on the packaging. REQUIRED ***NONE*** Aspirin Acetaminophen (Tylenol) Ibuprofen (Motrin/Advil) Naproxen Sodium (Aleve) Diphenhydramine HCL (Benadryl) Cough Drops Sunscreen Bug Repellent Please fill out this field.
  
  By entering into and/or signing this document, the signatory/signatories agree to conduct its/their dealings via electronic means. The signatory agrees that allowing dealings via electronic means will facilitate these dealings. The signatory has the option to opt to sign things in a paper format.
  I Agree Please select this field.
  
  Signature: (Parent/Guardian REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  Child Info 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Address if different from Primary Parent Please enter valid data.
  
  T-shirt Size (District Perfect Weight Tee DT 104L (ladies), DT 104 (unisex)) REQUIRED Please fill out this field.
  
  Food Allergies, Medication Allergies, Food Sensitivities/Intollerance REQUIRED Please fill out this field. Please enter valid data.
  
  Medications*- Rx, OTC, Vitamins / Glasses or Contacts / Other Pertinent Comments REQUIRED Please fill out this field. Please enter valid data.
  
  *All medication (prescription and over-the-counter) to be taken by your child during this event must be turned into the parish representative, along with THIS form, prior to departure, with full instructions as indicated on form. All medication must be in original packaging or in packaging provided by the pharmacy or doctor with instructions for administering the medication.
  I Agree Please select this field.
  
  The youth ministry's first aid kit contains common OTC Medications often taken "as needed". While we do not guarantee availability, are there any medicines you give us permission for us to provide to your child upon their request?
  
  By electronically signing below, you are hereby giving the parish team permission to dispense the selected medication(s) as directed on the packaging. REQUIRED ***NONE*** Aspirin Acetaminophen (Tylenol) Ibuprofen (Motrin/Advil) Naproxen Sodium (Aleve) Diphenhydramine HCL (Benadryl) Cough Drops Sunscreen Bug Repellent Please fill out this field.
  
  By entering into and/or signing this document, the signatory/signatories agree to conduct its/their dealings via electronic means. The signatory agrees that allowing dealings via electronic means will facilitate these dealings. The signatory has the option to opt to sign things in a paper format.
  I Agree Please select this field.
  
  Signature: (Parent/Guardian REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  STATEMENT OF CONSENT & RELEASE OF LIABILITY
  
  Dear Parent or Legal Guardian: Your son/daughter is eligible to participate in a parish-sponsored activity to a location away from the parish premises. This activity will take place under the guidance and supervision of employees/volunteers from Parish.
  As parent or legal guardian, you remain fully responsible for the actions and conduct of your child. This includes arranging and paying for transportation home in the event your child(ren) need to leave early or be removed due to illness or not following rules or code of conduct.
  
  Name of Event: Catholic Heart Work Camp Trip and Free Day Activities June 6-13, 2026
  Destination(s):
  SUIC Newman Center: 715 S. Washington Street Carbondale, IL 62901
  Catholic Heart Work Camp - Memphis, TN. - Housing/Programming: St. Benedict at Auburndale High School 8250 Varnavas Drive Cordova, TN 38016, Service work in the surrounding communities.
  City Museum: 750 North 16th Street St. Louis, MO 63103
  LaSalle Retreat Center: 2101 Rue De LaSalle Glencoe, MO 63038
  The Cathedral Basilica of St. Louis: 4431 Lindell Blvd, St. Louis, MO 63108
  St. Louis Zoo: 1 Government Drive St. Louis, MO 63110
  Designated Supervisor of Activity: Nicki Herold
  Date, Location & Time of Departure: June 6, 2026, 1pm St. Monica Catholic Church - Gather at 12:30 by 'drive through structure' behind parish offices. Eat before coming.
  Method of Transportation: Rented Vans and/or borrowed personal vehicles.
  Student Cost: $400 + Free Days Activity Fees, & Food during travel and free days.
  
  STATEMENT OF CONSENT
  I hereby consent to participation by my child(ren), [form will insert child's name from above registration field(s) here], in the event described above. I understand that this event will take place away from the parish grounds and that my child will be under the supervision of the designated parish employee and/or volunteers on the stated dates. I further consent to the conditions stated above on participation in this event, including the method of transportation.
  
  In consideration of my child(ren) being allowed to participate in this off-campus event, I hereby agree on behalf of myself and my child, to release St. Monica Catholic Church Parish, the Roman Catholic Diocese of Kalamazoo, and any and all affiliated organizations, their employees, agents and representatives, including volunteer drivers (collectively “Releasees”), from any and all claims, including negligence, which may be asserted by me or my child(ren), or on behalf on my child(ren), arising from or relating to my child(ren)’s participation in the off campus event. In the event this release on behalf of myself and/or my child(ren) is held to be invalid or unenforceable, I hereby agree to indemnify and hold harmless Releasees from any and all claims, including negligence, which may be asserted by me or my child(ren), or on behalf of my child(ren), arising from or relating to my child(ren)’s participation in the off-campus event. This release or indemnification does not apply to claims for intentional misconduct or gross negligence: nor does this release or indemnification apply to the extent of commercial insurance coverage for any claim, but this Release or Indemnification shall apply to the extent of any selfinsurance or deductible applicable to any claim.
  
  By entering into and/or signing this document, the signatory/signatories agree to conduct its/their dealings via electronic means. The signatory agrees that allowing dealings via electronic means will facilitate these dealings. The signatory has the option to opt to sign things in a paper format.
  I Agree Please select this field.
  
  Signed: (Parent/Guardian Name) REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Minor: REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  Who may pick up your child(ren)? Include your teenage driver if they are allowed to self transport. REQUIRED Please fill out this field. Please enter valid data.
  
  MEDICAL TREATMENT INFORMATION & AUTHORIZATION
  
  Family Physician Data
  
  Physician/Office 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.
  
  Phone Number REQUIRED
  
  Please fill out this field. Please enter a phone number.
  
  Health Insurance Data
  
  Company REQUIRED Please fill out this field. Please enter valid data.
  
  Group # REQUIRED Please fill out this field. Please enter valid data.
  
  Policy # REQUIRED Please fill out this field. Please enter valid data.
  
  Contract REQUIRED Please fill out this field. Please enter valid data.
  
  MEDICAL RELEASE
  To Whom It May Concern:
  As a parent/guardian, I do hereby authorize the treatment by a qualified and licensed physician of any condition which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me.
  
  I further authorize the person who presents the minor to sign the Acknowledgment of Receipt of Notice Privacy Rights that may be presented by the physician or health care facility. By entering into and/or signing this document, the signatory/signatories agree to conduct its/their dealings via electronic means. The signatory agrees that allowing dealings via electronic means will facilitate these dealings. The signatory has the option to opt to sign things in a paper format. I fully understand and agree to the above terms and sign this form knowingly, willingly and freely.
  
  This authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician.
  I Agree Please select this field.
  
  Signed (Parent/Guardian) REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Minor: REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  PHOTO RELEASE
  I hereby grant permission to St. Monica Parish to publish my child(ren)'s name, photo, or video image in connection with a display, feature story or other publication as deemed appropriate by the above-named parish or the Diocese of Kalamazoo.
  
  This photo may be used in connection with: parish bulletin boards, parish or diocese publicity materials, parish, school or diocese website, and parish, school, or diocese social media.
  
  By entering into and/or signing this document, the signatory/signatories agree to conduct its/their dealings via electronic means. The signatory agrees that allowing dealings via electronic means will facilitate these dealings. The signatory has the option to opt to sign things in a paper format.
  I Agree Please select this field.
  
  Signed: (Parent/Guardian) REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  Submit

Saint Monica Catholic Church

Kalamazoo, mi

CATHOLIC HEART WORK CAMP RELEASE Forms

2026 Catholic Heart Work Camp Registration and Release Form

Family Information