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EPIC Youth Conference

- Faith Formation

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- Dear Parent or Legal Guardian,
  Your son/daughter is eligible to participate in a parish-sponsored activity requiring transportation to a location away from St. Mark the Evangelist premises. This activity will take place under the guidance and supervision of staff/volunteers from St. Mark the Evangelist Catholic Community.
  Name of Event: EPIC Youth Conference
  Place of Event: St. Gerard Parish Hall, Lansing, MI
  Designated Supervisor of Activity: Brittany Carroll, Youth Minister at St. Mark the Evangelist Catholic Community, and other Adult volunteers from St. Mark the Evangelist Catholic Community
  Date and Time of Departure: Saturday, January 25, 2025 11:30 am St. Mark Parking lot
  Date and Time of Return: Saturday, January 25, 2025 10:00 pm St. Mark Parking lot
  Method of Transportation: TBD
  Student Cost: $25.00
  Emergency Phone: 810-869-9329 (Brittany’s cell)
  If you would like your child to participate in this event, please complete the following statement of consent and release of liability by filling out the form below. As parent or legal guardian, you remain fully responsible for the actions and conduct of your child.
- Date: Please enter valid data.
- Parent's First and Last Name REQUIRED Please fill out this field. Please enter valid data.
- Child's First and Last Name REQUIRED Please fill out this field. Please enter valid data.
- Cell Phone Number Please enter valid data.
- Home Phone Number Please enter valid data.
- Child's Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Email REQUIRED Please fill out this field. Please enter an email address.
- My child is allergic to: Please enter valid data.
- My child must take the following medication. (Include dosage and frequency) Please enter valid data.
- Please note specific medical problems. Please enter valid data.
- In case of an emergency notify: REQUIRED Please fill out this field. Please enter valid data.
- Emergency phone number: REQUIRED Please fill out this field. Please enter valid data.
- Family Health Plan Please enter valid data.
- Family Health Plan Number: REQUIRED Please fill out this field. Please enter valid data.
- STATEMENT OF CONSENT: I hereby consent to participation by my child in the event described above. I understand that this event will take place away from the parish grounds and that my child will be under the supervision of the designated parish staff/volunteers on the stated dates. I further consent to the conditions stated above on the participation in the event, including the method of transportation. I also agree to allow appropriate photographs and videos of my child on this event to be used by St. Mark the Evangelist Catholic Community for information and promotional purposes only. In consideration of my child being allowed to participate in the field trip, I agree to indemnify and hold harmless St. Mark the Evangelist and all affiliated organizations, their employees, agents, and representatives, including volunteers and other drivers, from any and all claims including negligence, arising from or relating to my child's participation in this field trip. This indemnification and hold harmless agreement does not apply to claims for intention misconduct or gross negligence.
- I Agree Please select this field.
- HEALTH PERMISSION FORM: I grant permission for non-prescriptive medication (e.g. Tylenol, throat lozenges, cough syrup, pepto-bismal) and routine nonsurgical medical care to be given to my child if deemed advisable by the supervising parish personnel. In case of emergency, I also grant permission to transport my child to the nearest hospital for emergency medical or surgical treatment. I will be contacted as soon as possible and will be advised prior to any further treatment by the hospital or doctor. In the event it is impossible to contact, I consent and authorize St. Mark the Evangelis Catholic Community and its agents to consent to any necessary steps that will secure my child's health and safety under the advice of a licensed physician/surgeon (examination, anesthesia, diagnosis, treatment, surgery, and hospital care are included) as governed by the laws of the State where medical treatment is being sought. I understand that I am responsible for any and all costs incurred by the above actions being conducted.
- I Agree Please select this field.
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St Mark Evangelist Catholic Community

7296 Gale Road Grand Blanc, MI
810-636-2216

7296 Gale Road
Goodrich/Grand Blanc, MI

EPIC Youth Conference