Quest 2022 Permission & Health Form
Dear Parent or Legal Guardian:

Your daughter/son has requested permission to participate in:

      QUEST 2022, a program sponsored by St. Joseph the Worker Church, Chatham

We have decided to do the permission and health form online to cut down on paper, etc.
A description of the event follows:

NAME OF EVENT:                         QUEST 2022
DATE(s) of EVENT:                         Wednesday, June 29 - Thursday, June 30
Time of EVENT:                                        Drop Off Wednesday - 6:00 pm–Pick Up Thursday at 5:00 pm
ACTIVITIES INVOLVED:                         Overnight Retreat and Team Building
Event Takes Place at:                         St. Joseph the Worker, Chatham
Under the Supervision of:                         Riana Cattoor and Dawn Roesch


If you wish your child to participate in the above described event, please read, complete, sign, and submit the following statement of consent and release of liability:

I request that my child be allowed to participate in “QUEST 2022,” described above.  I grant permission for him/her to attend this event and release and agree to indemnify and hold harmless St. Joseph the Worker Catholic Church and all persons connected with this event from any liability, claims, or damages for personal injury, or property loss or damage that may result during the event.  My signature gives authorization to the above named entity to secure treatment for my child by emergency personnel in the event of an accident after reasonable effort has been made to reach me.  I also grant permission for St. Joseph the Worker to publish photos of my child on its website (http://www.stjoschatham.org) as she/he may be participating in this activity.  I understand that names will not be posted on the website, only photos.

My signature below gives authorization to the above named entity to secure treatment for my child by emergency personnel in the event of an accident after reasonable effort has been made to reach me. My signature also verifies that I understand that, while all measures are being taken, to the best of our ability, to prevent the spread of Covid19, I will not hold St. Joseph the Worker liable if my child would happen to contract the virus while attending Quest.  


We do need one filled out per child this time since we are including the health history on here.  

If you wish your child to participate in the above described event, please read,
complete & sign this form.



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Date: *
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Parent Email Address *
Parent Phone Number *
Will your youth be staying overnight? *
If youth is not staying overnight, a parent must come pick them up between 11:30pm-12:30am (Monday night/Tuesday morning) and bring them back to the church by 6:50am Tuesday morning. *
Youth Gender *
Youth Name (first and last) *
Grade (incoming) *
t-shirt size (all adult) *
Are immunizations up to date? *
Date of last tetanus shot *
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Has your child received the Covid 19 vaccine? *
Illnesses and Injuries (check any that child currently has or has had in the past)* *
Required
List Current Prescription Medicines being taken, Dosage and the Reason *
If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your youth is participating in the activity. Do you have health insurance? *
Does your youth have any food allergies *
Name of Primary Insured *
Relationship to Participant *
Insurance Carrier *
Policy or Group Number *
Family Physician Name and Phone Number *
IN CASE OF MEDICAL EMERGENCY, I understand that when medically feasible, every effort will be made to reach the parent/guardian listed on this form, but in the event one cannot be reached or if it is not medically feasible to contact one, I hereby give permission to the physician or dentist selected by the adult leaders to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary for treatment. I understand that all reasonable safety precautions will be taken at all times by St. Joseph Church and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold St. Joseph Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form. (Parent/Guardian Virtual Signature if youth is under age 18, Signature of youth if over age 18) *
Emergency Contact (Name, Relationship and Phone Number) *
Hospital Preferred *
Address *
City, State & Zip *
Youth birthday *
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Parent/Guardian Digital Signature                                                                                                                                    (Parent/Guardian Virtual Signature if youth is under age 18, Signature of Youth if over age 18) *
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