Confirmation Retreat September 2019 Posted August 1, 2019 Confirmation Retreat September 21, 2019 September Retreat - Saturday, September 21, 2019, 1pm - 10pm, St. Theresa Catholic Church Youth InformationName* First Last NicknameBirthdate (mm/dd/yy)*Gender*MaleFemaleAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Youth's Email* Grade*School*Interests and Hobbies*i.e. video games, hiking, sports, stamp collectingT-Shirt Size (adult sizes)*SmallMediumLargeExtra LargeEmergency Contact and Medical InformationEmergency Contact Adult's Name* First Last Relationship to Youth*Home Phone*Cell PhoneStudent Health InformationKnown allergies to any medicineAny other medical problems that should be notedParent/Guardian InformationParent/Guardian's Name (for event contact)* First Last Valid Email (for event information)* Home Phone*Cell PhoneParent/Guardian Information 2Parent/Guardian's Name 2 (for event contact) First Last Valid Email 2 (for event information) Home Phone 2Cell Phone 2I, the parent/legal guardian of the youth I have designated above, give permission for my child to attend a Parish Confirmation Retreat at St. Theresa Catholic School, 21370 St. Theresa Lane, Ashburn, VA 20147, Saturday, September 21st, 2019 from 1:00PM to 10:00PM. I understand and acknowledge that participation in the activities involves inherent risks of injury to my child. I do herby agree to release, indemnify and hold harmless chaperones, St. Theresa Parish, Youth Ministers, Volunteers, and the Catholic Diocese of Arlington for any costs or expenses arising out of my child’s participation in the activities including the cost of any medical care given my child or any expenses or fees incurred in any lawsuit arising as a result of any damage or injuries caused by my child in the course of his or her participation in the activities. I further give my consent that in my absence the above-named minor may be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. Photo/Video: Also, I authorize St. Theresa’s Youth Ministry and the Catholic Diocese of Arlington to use my child's picture or video recording for educational purposes and/or marketing purposes. Parents/guardians who do not wish their child to be photographed or filmed should notify the Religious Education Office in writing. I freely execute this Acknowledgement with full knowledge of its content. I understand that in the event my child becomes ill with a communicable illness during the retreat, I have to make immediate arrangements to retrieve my child from the retreat.Parent/Guardian's Signature*Date* Date Format: MM slash DD slash YYYY RemarksCommentsThis field is for validation purposes and should be left unchanged.