Shine Youth Rally 2018

Dear Parent of Legal Guardian:
Your child is eligible to participate in a parish-sponsored activity requiring taking place West Catholic High School. This activity will take place under the guidance and supervision of employees from Our Lady of Consolation Parish. A brief description of the activity follows:

Name of Event: Shine Youth Rally
Location: West Catholic High School, 1801 Bristol Ave. NW, Grand Rapids, MI 49504
Supervisor of Activity: Josh Hanson 616-866-2577 x217
Date, Time, & Drop Off: Saturday, March 24, 2018, at 1:30 PM (registration opens); 2 PM (retreat starts), West Catholic High School
Date, Time, & Pick Up: Saturday, March 24, 2018, at 8:30 PM, West Catholic High School
Method of Transportation: Own
Cost: $45 at the door

I authorize Our Lady of Consolation Parish to obtain necessary medical treatment for my child in case of illness, injury, or accident.

Student Name:
Address: , , MI,

Parent/Guardian Name:
Parent Phone: or
Parent Email:
I certify that I am the of the minor child named above and I agree to the above terms for myself and for my minor child.

Emergency Contact other than parent:
Emergency Contact will only be contacted if parent is not available

Allergies, Restrictions or Recommendations


Family Physician:

Health Insurance Data
**If your policy does not have some of these areas of information, please enter NONE**
Policy Number:
Group Number:
Contract Number:

Consent for Participation:
I hereby consent to participation by my child in the event described above scheduled for March 24, 2018. I understand that this event will take place off parish grounds. I further consent to the conditions stated above on participation in this event, including the method of transportation.

In consideration of my child being allowed to participate in this event, I agree to waive and release, and indemnify and hold harmless
Our Lady of Consolation Parish, any and all affiliated organizations, its/their employees, agents, representatives, volunteers and
drivers, from any and all claims I or my child may have, excluding claims for intentional misconduct or gross negligence, arising from
or relating to my child’s participation in this event.

Consent for Medical Treatment:
As a parent/guardian, I do hereby authorize first aid/medical treatment of my child in the event of an emergency which may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed. It is understood that efforts will be made to reach me as soon as reasonably possible.

Consent for Photo & Media Consent:
As legal guardian of the aforementioned child to participate in the Our Lady of Consolation Parish Formation Programming. I understand that photography and/or video of participants may be procured during Formation Programming and used in promotional materials. I consent to the use of images and likenesses of the aforementioned person, for promotion purposes by Our Lady of Consolation Parish, including the Our Lady of Consolation Parish website and Facebook page.