YOUTH 2OOO NY REGISTRATION FORM FOR ADULTS AND YOUTH Liability Release Form Release Of All Claims

Name of Activity: RETREAT WEEKEND Date of Activity: September 21,22,23, 2012 The Undersigned do hereby release, forever discharge and agree to hold Monsignor Farrell High School and YOUTH 2OOO New York, Inc., harmless from and against any and all liability, claims, demands, lawsuits, and expenses arising from personal injury, sickness, death, or property damage any nature whatsoever which may be incurred or suffered by the undersigned and/or the participant (if the participant is under 18 or 18 and older) while attending the Youth Retreat. Furthermore, the undersigned hereby assumes all risk of personal injury, sickness death, damage and expense arising from the undersigneds or participants (if participant is under 18 or 18 and older) participation in all activities including recreation and work activities involved in the Youth Retreat. Further, authorization and permission is hereby given to furnish all necessary transportation, food and lodging for the undersigned or participant (if participant is under 18 or 18 and older). The undersigned further hereby agree to indemnify and hold Monsignor Farrell High School and YOUTH 2OOO New York, Inc. and their respective members, directors, employees and agents (collectively, the Indemnities), harmless from and against any and all claims, demands, actions, lawsuits and liabilities, including attorneys fees and expenses sustained by the Indemnities as the result of the negligent willful or intentional acts of the undersigned and/or participant (if participant is under 18, 18 or older). If participant is under 18 years of age: We (I) are the parent(s) or legal guardian(s) of the participant and hereby grant permission for my child to participate fully in the Youth Retreat and all of its activities and hereby grant our permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not limited to emergency surgery and, we fully and completely assume responsibility for all medical bills. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, I (we) assume all responsibility and transportation costs.

I HAVE READ AND AGREE TO THE ABOVE AND HAVE LISTED ANY SPECIAL NEEDS ON THIS FORM.(BACK)
NO ONE under 18 years of age is permitted to leave this function without prior, written permission from parent or legal guardian. This form must be signed by all participants. If participant is under 18, both parents, or custodial parent, or legal guardian MUST SIGN: Name of participant____________________________________________________Age_________M________F_______ Address_____________________________________________________________________Apt____________________ City_______________________________________________________State___________________Zip______________ Telephone ( )___________________________________________________________________________________ Parent(s)/Legal Guardian Signature______________________________________________Date____________________ Participants Signature________________________________________________________________________________ Parish/Group_______________________________________________________________________________________ Adult Leaders Name______________________________________(One leader for every group of 7 youth under age 18) Is this your first YOUTH 2OOO Retreat? Yes ________No _______ MEDICAL INFORMATION: (Please fill in all information) Physician Name__________________________________________ Phone #______________________________________ Allergies:_______________________________________________Medications:___________________________________ Medical History:______________________________________________________________________________________ Participants Social Security Number:_____________________________________________________________________ IN CASE OF EMERGENCY PLEASE CONTACT: Name_____________________________________________ Name_______________________________________ Address___________________________________________ Address_____________________________________ _________________________________________________ ____________________________________________ Phone (H)__________________(Cell)__________________ Phone (H)_________________(Cell)______________ Relationship_______________________________________ Relationship____________________________________ FOR ADULT CHAPERONES (PLEASE COMPLETE THE FOLLOWING) Diocesan Safe Environment Training/ Virtus is required of all adult chaperones. Additionally adult chaperones must be up to date with their training and have had a background check completed by their diocese. Have you completed your Dioceses Safe Environment Training Yes _________ No ________ Are you currently up to date with your training Yes ________ No _________ Has your diocese run a back ground check for you Yes _______ No _________ If you answered no to any of these, please take the necessary steps to correct this situation prior to submitting you registration form.