Youth 2 Youth Registration Home / Youth 2 Youth Registration Youth 2 Youth Registration "*" indicates required fields Step 1 of 10 10% Retreat InformationDATE & TIME OF EVENT: Saturday, April 26, 2025: 9:00am – Sunday, April 27, 2025: 4:00pm at Camp Rotary DESTINATION: Camp Rotary; 3201 S. Clare Ave; Clare, MI Phone: 989-386-7943 DESIGNATED SUPERVISOR OF ACTIVITY: Melissa Kato (989.751.8182) Kathy Russell (989.600.1112) Camp Rotary (989.386.7943) CHAPERONES: Richard Adam, Derek Haddad, Ty Mier, Wendy Sheilds, Kim White METHOD OF TRANSPORTATION: Carpool DRIVERS NEEDED(Please note: The minimum acceptable liability limits for a privately owned vehicle is $500,000 CSL [Combined Single Limit] or an Umbrella Policy. Drivers must fill out a Volunteer Driver Information Sheet located in the Faith Formation Office and have both sides of your drivers license copied.) Adult Chaperones: If you can spare some time to help keep our kids safe during our time together, please mark “yes” on this form or call Melissa or Kathy. COST: $70.00 Student Information & PermissionStudent Name First Last Student AgeGradeGenderFemaleMaleChurch/ParishPermission*I , the parent of the aforementioned student request that Blessed Sacrament Parish and Assumption of the Blessed Virgin Mary Parish allow my son/daughter, to participate in the activity described above. I give permission for my child to participate in said trip. In consideration for my son’s/daughter’s participation, I hereby release, save harmless and indemnify Blessed Sacrament Parish and Assumption of the Blessed Virgin Mary Parish, its employees, volunteers, agents and any sponsors or benefactors of said trip from any and all liability from any and all injury. I understand that my son/daughter will be under the supervision of the designated supervisor and chaperons on the stated dates and that all parish rules listed below will be in effect. I understand and agree that, if my son/daughter violates a parish rule, he/she will be sent home. I agree.Medical InformationMedical Consent*In case medical treatment is necessary and the parents or guardian cannot be located, the following authorization is needed, I (We) authorize the adult advisor in charge to consent to any neces¬sary examination, anesthetic, medical diagnosis, surgery or treatment, and/or hospital care to be rendered to the above named minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine in the state of Michigan. I agree.Allergies:Chronic diseases or medical problems:Medicines son/daughter is now taking:Medicines that need to be dispensed during this activity must be given to the designated supervisor in its original container with directions and dosage.Medical Insurance Carrier:*Policy/Contract Number:*Family Physician:*Physician Phone:*Parent (Guardian) Name:*Parent/Guardian E-Signature Contact InformationAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent/Guardian Email Home Phone:Work Phone:Cell Phone:Emergency Contact Name:*Emergency Contact Phone:* Parish Event Participant Agreement:Coupling swearing, smoking, drinking, gambling, possession of alcohol, drugs, or firearms are NOT permitted at our church youth functions. Any youth found in violation of these rules will have their parents called and will be sent home.Teen Signature*Date MM slash DD slash YYYY Teen Cell Number (if applicable): Media ReleaseDuring the retreat, we will be taking photographs and/or videos for use by Blessed Sacrament to highlight the retreat in the following ways: website, brochures, flyers, announcement slides, and PowerPoint slide shows. This section allows you an opportunity to indicate if you you do, or do not, want your child photographed or videoed at the Youth 2 Youth Retreat.Please check one: YES, you have my permission NO, you do not have my permission Parent Initials Camp Rotary Hold-HarmlessCamp Rotary requires this hold-harmless form to be signed by each retreat participant and their parent/guardian if under 18. Please download the form, fill it out, and attach it on the next page.Download and Sign the Hold Harmless Form Please upload the signed hold-harmless form:Max. file size: 300 MB. PaymentPlease click here to pay online. This will open a new window to our Vanco payment page. If you would like scholarship help to offset the cost of the retreat, please email Melissa Kato. How did you hear about the retreat? Social Media Bulletin Mass Email/Text Personal Invite Who invited you? Carpool DriverAre you interested in driving to or from the retreat? No Yes Name First Last Email PhoneHave you attended VIRTUS? Yes No I can help with… Driving only TO Driving only BACK Driving both TO & BACK How many YOUTH can you take (also taking into account luggage)?Year/MakeLicense Plate #ExpiresInsurance CompanyPolicy #ExpiresI certify that the information given on this form is true and correct to the best of my knowledge. I certify that as a volunteer driver, I hold a valid driver’s license and have the required insurance coverage in effect on this vehicle. The undersigned driver agrees to indemnify, hold harmless and defend the Midland Area Catholic Churches together with their employees, agents and representatives from any and all claims for damage to a person or property caused in part or wholly by the undersigned. Please note: The minimum acceptable liability limits for a privately owned vehicle is $500,000 CSL [Combined Single Limit] or an Umbrella Policy. Drivers must fill out a Volunteer Driver Information Sheet located in the Faith Formation Office and have both sides of your drivers license copied.SignatureDate MM slash DD slash YYYY ChaperonesAre you interested in being a chaperone? No Yes Some chaperones will be asked to be in the cabins. (In most cabins, wifi is available.) The idea with this is so that youth cannot go to the cabins to be alone with one another. This includes the times during Mass and reconciliation (so you would not be able to attend during retreat). Some chaperones will be asked to walk the grounds. We are also asking that chaperones bring their own meals if needed.I am willing to volunteer for the following hours to chaperone: Saturday: 10am-2pm Saturday: 2pm-6pm Overnight: 6pm-8am Sunday: 8am-12pm Sunday: 12:00pm-3:30pm Select AllHave you attended VIRTUS?Required for overnight chaperones Yes No NameThis field is for validation purposes and should be left unchanged.
