Holy Cross Catholic Church

Participant Name *

First Name

Last Name

Sex *

Male

Female

Grade *

6

7

8

9

10

11

12

Parent/Guardian Name(s) *

First Name

Last Name

Parent Phone (Emergency Contact Phone #1) *

(###)

###

####

Emergency Contact #2 (must be different from #1) *

First Name

Last Name

Emergency Contact #2 Phone *

(###)

###

####

Are you, the parent, available to drive and/or overnight chaperone? *

I/we can drive if needed

I/we can overnight chaperone if needed

I/we can drive AND chaperone if needed

I/we are unavailable this weekend

Medical Release: In an emergency, Holy Cross Parish, and its designated representative(s), will contact the above-listed persons and seek emergency medical treatment for my youth. I agree to hold harmless Holy Cross Parish and said representative(s), from any accident or illness requiring such treatment, and from the results of any such treatment. *

Yes

No

Photo Release: I/We, the parent(s)/guardian of the child/youth authorize and give full consent, without limitation or reservation, to Holy Cross Parish, to publish any photograph or video in which the above-named student appears while participating in any program associated with Holy Cross Parish. There will be no compensation for use of any photograph or video at the time of publication or in the future. *

Yes

No

Payment Method *

Cash or check (dropped in the collection in an envelope marked "Winter Retreat fees")

Credit card (online via the "Give" button in the top corner of the website, with comment "Winter Retreat fees")

I will find you after Mass so you can process my credit card in-person

I would like to apply for a scholarship