Our Lady of Hope Church
Our Lady of Hope Youth Group
9711 West Devon Avenue
Rosemont, IL 60018
847-825-4673
MAY 3, 2015
Adult Participants Over 26 Years of Age:
Read this carefully!!!
If you wish to participate in the Wisconsin Summer Service Trip you
MUST do the following;
1. GET THE ALL FORMS
COMPLETELY
FILLED IN.
2. ATTACH COPIES OF THE
FRONT AND BACK
OF MEDICAL INSURANCE AND
PRESCRIPTION CARDS AND A DRIVERS LICENSE OR STAE I.D. CARD.
3. RETURN THE THREE PERMISSION SLIPS, I.D. COPY, THE MEDICAL
CARD COPIES TO OUR LADY OF HOPE NO LATER THAN 11:00 A.M. ON June 7, 2015.
4. PUT THE ABOVE IN AN ENVELOPE ADDRESSED TO “DEACON JIM” AND TURN INTO THE
OFFICE.
5. SEE ATTACHED LIST OF ITEMS TO BRING. PACKING IS LIMITED, SO PLEASE BRING ONLY
THE NECESSITIES.
ALL CLOTHING MUST BE MODEST IN NATURE.
7. YOU MAY WANT TO BRING ABOUT $20-$40 CASH FOR SPENDING. WE MAY BE GOING
SOME PLACES AND YOU MAY WANT TO SHOP.
8. WE WILL RETURN APPROXIMATELY 2:00 P.M. ON JULY 25, 2015. PLEASE ARRANGE FOR
PROMPT PICK-UP AT THE OUR LADY OF HOPE PARKING LOT.
DEACON JIM
Trip Emergency Numbers:
Deacon Jim: 847-989-4631; Mrs. Ernst: 630-817-4631; Mr. Kaisling:
847-826-1312; Camp Daniel Office: 715-757-3880
Our Lady of Hope Church
Our Lady of Hope Youth Group
9711 West Devon Avenue
Rosemont, IL 60018
847-825-4673
___________________________________________
Permission Slip – adult 26 or older - 2015 Summer Service Trip to Athelstane, WI.
___________________________________ ________/________/________ __________________________ PARTICIPANT NAME DATE OF BIRTH (MM/DD/YYYY) HOME PHONE NUMBER ______________________________________________________________________________________________ ADDRESS CITY STATE ZIP
I, __________________________________, will be a participant in the 2015 Our Lady of Hope Youth Group Summer Service Trip to Athelstane, WI during the period of July 19, 2015 until July 25, 2015. I understand that participation in this trip includes car, van, and and/or bus transportation; the use of tools, both power and manual, and assorted implements all of which may have inherent risks. I hereby release and indemnify the staff and volunteers of Our Lady of Hope parish; the Catholic Bishop of Chicago, an Illinois corporation sole; Camp Daniel, Inc. of Athelstane, WI; and all other properties and volunteers associated with this Our Lady of Hope Youth Group function, from any and all liability arising from claims of any kind or nature, whatsoever, from my participation in this event and all activities associated with this trip. I
understand that I am subject to acceptable rules of behavior while on this activity. I also understand that I will be required to leave the activity location, if I fail to act in a proper manner. I also agree that improper actions will be judged at the discretion of the Our Lady of Hope Parish delegated adult leaders of this activity. Should I be injured, I give the adult leaders my permission to have any emergency care given to me in the event that my emergency contacts/physician cannot be immediately contacted. I also agree to inform the Youth Group Coordinator at Our Lady of Hope Church of any changes to the following information. I authorize Our Lady of Hope Church/Youth Ministry to use my picture, without my name, for educational and marketing purposes. This permission may be rescinded by written request to Our Lady of Hope Youth Ministry. The participant agrees to be at Our Lady of Hope Church at 9:00 a.m. on July 19, 2015, attend 9:30 a.m. Mass and the participant will be prepared to depart after Mass.
This form and all other related documents needed for participation must be turned in no later than 11:00 a.m. on June 7, 2015.
__________________________________ _____________________________ _______________________ PARTICIPANT’S SIGNATURE DATE MEN’S “T” SHIRT SIZE
__________________________________ _____________________________ WITNESS TO ABOVE SIGNATURES DATE
(AN ADULT OVER 21 MUST SIGN) EMERGENCY CONTACTS
1)___________________________________________ ___________________________________ NAME/RELATIONSHIP TO PARTICIPANT PHONE NUMBER
______________________________________________________________________________________
ADDRESS CITY STATE ZIP
2)___________________________________________ ___________________________________ NAME/RELATIONSHIP TO PARTICIPANT PHONE NUMBER
______________________________________________________________________________________
ADDRESS CITY STATE ZIP
NOTE: THIS PERMISSION SLIP MUST BE USED, NO OTHER WRITTEN OR PHONE PERMISSION WILL BE ACCEPTED.
Our Lady of Hope Youth Group
9711 West Devon Avenue
Rosemont, IL 60018
847-825-4673
Medical permission form –over 18 yrs. old
Our lady of hope youth group trip
To Athelstane, WI – July 20 - 26, 2014
I, ________________________________ hereby grant permission for the administration of medical
treatment and/or first aid to me by any adult volunteer involved in the above stated activity and by those
transporting me, as part of this activity, as their judgment deems advisable. I grant permission for these same
individuals to make any necessary referrals to qualified physicians for the treatment of illness or accidents of a
more serious nature. I understand that my emergency contact or my parent/guardian, if responsible for my
health insurance, will be promptly notified in the event of any serious illness or accident and prior to any major
surgery, except when a delay in such communication would endanger my life and that in case of such a
medical emergency, I understand that every effort will be made to contact same as soon as possible. In the
event that they cannot be reached, I hereby give permission to the physician selected by the adult staff to
hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery, if deemed necessary for
my treatment. I also understand that I have not been given any guarantee as to the results of examination or
treatment.
______________________________________________
________________________
Signature of Participant
Date
______________________________________________________________________________
Address
City
State
ZIP
_________________________ _______________________ __________________________
Home Telephone
Work Telephone
Other Contact: Cell Phone/Pager
___________________________________________
________________________
Authorized Physician (Print Name)
Phone Number
___________________________________________
________________________
Insurance Company
Policy Number
Please list any medical concerns, allergies and or medications you are currently taking.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
YOU MUST ATTACH COPIES OF BOTH FRONT AND BACK OF YOUR INSURANCE AND
PRESCRIPTION CARDS AND A PHOTO COPY OF A CURRENT I.D. OF THE PERSON WHO'S
NAME APPEARS ABOVE.
our Lady of Hope youth group
summer service trip
personal material list
Each participant should bring the following items on the Summer Service Trip:
(Clothing is for six days)
Sleeping Bag
Sleeping Attire
Pillow (Only One)
Construction Type Work Boots
--
Must be worn on the work site.
Work Pants (2-3 pr.)
--
Must be worn on the work site.
5 T-shirts for the work site – no exposed midriff.
Plastic (Emergency) Rain Poncho
Clothes to relax in after work.
--Shorts, Gym shoes, etc.
--Modesty will be in force
Socks, thick, above ankle or boot top.
Underwear
Sweatshirt or light jacket
1 or two hats for the worksite
1 set of nice casual clothes
--for our night out for dinner.
Medications you need
Back Pack for the trip
Swim suit--modesty!!
Lunch and drink for ride to Camp Daniel
Extra Batteries for your needs & electronics
One Bag
with all your clothes, etc.
Sunglasses
Sun Screen
Insect Repellant
Bath Towel
Toothbrush
Toothpaste
Soap
Shampoo
Other needed Personal Hygiene Items
Beach Towel
Camera --put your name on it.
Leather Gloves - Labeled with name
Safety Goggles ($ Store)--put your name on it
1Qt. Refillable Water Bottle
No pre-packaged water in bottles
Cookies – 1 package to serve 12 people.
We will also need four “Boom Boxes” for the group, two for the work site.
Notes: ___________________________________________________________________________________
KEEP THIS PAGE - DO NOT TURN IN
9711 West Devon Avenue
Rosemont, IL 60018
847-825-4673
Youth Group – Adult participation – over 26 – All Events – JULY 2015 – JUNE 2016**
I _______________________________, plan to attend any or all of the Our Lady of Hope Youth Group activities from July 1, 2015 until June 30, 2016. I understand that signing this permission slip does not require me to attend all
scheduled events. I understand that participation in these activities may include car, van, and and/or bus transportation; the use of tools, both power and manual, and assorted implements all of which may have inherent risks. I hereby release and indemnify the staff and volunteers of Our Lady of Hope parish, and the Catholic Bishop of Chicago, an Illinois
corporation sole, and all other properties and volunteers associated with these Our Lady of Hope Youth Group functions, from any and all liability arising from claims of any kind or nature, whatsoever, from the above person’s participation in these events and all activities associated with these events. I understand that I am subject to acceptable rules of behavior while on these activities. I also understand that I will be required to leave any activity location, if I fail to act in a proper manner. I also agree that improper actions will be judged at the discretion of the adult leaders of each activity. Should I be injured, I give the adult leaders my permission to have any emergency care given I understand that the person responsible for my insurance, if not myself, will be contacted in a reasonable amount of time and that one of my emergency contact s will also be contacted. I also agree to inform the Youth Group Coordinator at Our Lady of Hope Church of any changes to the following information. (______Initial)
I authorize Our Lady of Hope Church/Youth Ministry to use my picture for educational and marketing purposes and these pictures may be published on the Our Lady of Hope Website, Facebook Page and/or in the Our Lady of Hope Bulletin, without the use of my name. I also give permission for Deacon James Ernst, Mrs. Rose Ernst, Mr. William Kaisling and/or Ms. Kimberly Rose permission to communicate directly with me about Youth Group or Church business through electronic means, including e-mail and/or text messaging or cell phone contact. Any part of this permission may be rescinded by written request to Our Lady of Hope Youth Ministry, Attention Fr. John Clemens. (_____ Initial)
PLEASE BE PROMPT!!! Participants should arrive at Our Lady of Hope Church at the time stated for each event. Rides will leave five minutes after that time. Reservations are needed for each event. It is the responsibility of each
participant to inform the coordinator for each event, in advance, if they will be attending.
___________________________________ ____________________________________ _________________ PARTICIPANT’S SIGNATURE PARTICIPANT’S E-MAIL DATE ________________________________ _________________________ ______________ ___________________ PARTICIPANT’S STREET ADDRESS CITY ZIP MEN’S “T” SHIRT SIZE __________________________ ______________________________ _________/__________/__________ PARTICIPANT’S HOME PHONE PARTICIPANT’S CELL PHONE PARTICIPANT’S D.O.B (mm/dd/yyyy) ______________________________ _________________________________________________________ EMERGENCY PHONE #1 NAME/RELATIONSHIP TO PARTICIPANT
______________________________ _________________________________________________________ EMERGENCY PHONE #2 NAME/RELATIONSHIP TO PARTICIPANT
MEDICAL INFORMATION:
___________________________ _______________ ____________________________ _______________ INSURANCE COMPANY NAME POLICY NUMBER DOCTOR’S NAME PHONE NUMBER
MISC. MEDICAL INFORMATION: PHYSICAL RESTRICTIONS, ALLERGIES, CURRENT MEDICATIONS, AND MEDICATIONS YOU ARE ALLOWED TO TAKE AT ANY TIME: (Include over-the-counter medications.)
___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
**THIS PERMISSION SLIP MUST BE USED, NO OTHER WRITTEN OR PHONE PERMISSION WILL BE ACCEPTED.
