Mount 2000 – A Retreat for High School Students Posted October 30, 2019 Mount 2000 High School Retreat Departure at 2:30 pm, Friday, February 7th, 2020 returning on Sunday, February 9th, 1:15pm. Mount St. Mary’s University, 16300 Old Emmitsburg Rd, Emmitsburg, MD 21727. The cost is $120. You will be redirected to a payment page upon form submission. Youth InformationName* First Last NicknameBirthdate (mm/dd/yy)*Youth's Email* Grade*School*Interests and Hobbies*T-Shirt Size*SMLXLXXLEmergency Contact and Medical InformationEmergency Contact Adult's Name* First Last Relationship to Youth*Home Phone*Cell PhoneStudent Health InformationFamily Physician*Physician's Phone*Known allergies to any medicineAny other medical problems that should be notedInsurance InformationInsurance Carrier*Policy Number*Phone*Parent/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 High School Retreat from Friday, February 7th, 2020 to Sunday, February 9th, being held at Mount St. Mary’s University in Emmitsburg, Maryland. I understand and acknowledge that participation in the activities involves inherent risks of injury to my child including risks associated with transportation by motor vehicle. 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 trip, I have to make immediate arrangements to retrieve my child from the trip location.Parent/Guardian's Signature*Date* Date Format: MM slash DD slash YYYY RemarksPhoneThis field is for validation purposes and should be left unchanged.