PAYMENT REQUIRED AT THE BOTTOM OF THIS FORM
Registration is $395 after March 1st which includes conference registration, lodging at The Centennial for 2 nights, 5 meals, transportation, and conference shirts.
If you need assistance with the cost, scholarships are available. Please contact Anne Sweeney.
Please fill out this form for each participant. Thank you!
All fields required unless otherwise noted.
Parent/Family Information.
Please include your email as you will receive a confirmation after submitting the form.
If the above parent/legal guardian CANNOT BE REACHED, the emergency contact below will be contacted.
Your emergency contact must be someone other than a parent/legal guardian.
Considerations and Medical Information
Write "NA" if not applicable
All Information will be kept confidential and will only be used if needed.
Please make note of any dietary needs, health considerations, or other needs that the participant has, so that we can have the most successful weekend possible! - Thank you!
Is participant subject to homesickness, emotional reactions to new situations, sleepwalking, bedwetting, fainting? (etc.)
Has the Child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc.
PARENTAL PERMISSION:
I, the parent or legal guardian of the child named on this form, give my permission for the above named child to participate in this event that may require transportation away from the parish site. This event will take place under the guidance and direction of parish employees and/or volunteers from Mary Queen of Peace Sammamish 7/12/24 - 7/14/24.
As a parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor ("participant"). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns to hold harmless and defend Mary, Queen of Peace its officers, directors, employees and agents and the Archdiocese of Seattle, its employees and agents, chaperones or representatives associated with this event, and I agree to compensate the parish, its officers, directors and agents and the Archdiocese of Seattle from any claim arising from or in connection with my child attending the event or in association with any illness or injury (including death) or cost of medical treatment in connection there within, and I agree to compensate the parish, its officers, directors and agents and the Archdiocese of Seattle, its employees and agents, chaperones or representatives associated with this event for reasonable attorney's fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/diocese.
Please type your full name below to acknowledge.
PHOTOGRAPHY/VIDEOGRAPHY RELEASE:
From time to time, pictures and video may be taken of events and gatherings. We would like to be able to use these photographs and videos for flyers, parish and diocesan publications, and the ministry website. If there are concerns about pictures or videos posted on the website, please contact the Youth Minister at anne.sweeney@mqp.org they will be promptly removed.
I/we, the parent(s)/guardian(s) of this youth authorize and give full consent, without limitation or reservation, to Mary, Queen of Peace (Sammamish, WA) to publish any photograph or video in which the above named student appears while participating in the Steubenville Conference 2024. There will be no compensation for use of any photograph or video at the time of publication or in the future.
Rooms Reservations
We are going to be staying at The Centennial Hotel in Spokane! The sponsoring ministry, Spiritus Ministries Northwest, for Steubenville NW reserved a hotel block for us. This means we have to book the rooms ahead of time for our teens, Priests, parent chaperones, youth ministers, etc. Due to the limited space, we are asking for your permission to have teens of the same sex share rooms including having them sleep on cots on the floor. Each teen will have their own sleeping space, either sleeping in a hotel bed or on a cot on the floor.
If you have concerns about this please contact Anne Sweeney.
Disclaimer
By submitting this form you are consenting that everything above is true to the best of your knowledge and/or you consent to the disclosed permissions.
