Emergency Rooms Release Forms

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Emergency Rooms Release Forms Powered By Docstoc
					                                                            John 6 - Crossing # 11
                                                          Liebenzell Retreat Center
                                                80 Pleasant Grove Road, Long Valley, NJ 07853
                                                             October 22 - 24, 2010
        This form (Excel format) is intended for ALL who will be attending the John 6 Crossing. Please fill in the required                           Rev 082410
                  fields and return an electronic copy to boyetzita_cruz@yahoo.com ASAP. Signed hard copies                                            J6-App (#)
        with any required payment and/or other documentation should follow & be submitted to the John 6 Ministry Head at
                  least one week prior to the Crossing date. Confirmation email will be sent out when accepted.

       ##   Please 'check' one button below:
       ##   Adult Auxie                                     ##   Ministry Head                                ##   Sponsor (J6)
       ##   Auxie - Other                                   ##   Moderator                                    ##   Sponsor Class Shepherd (J6)
       ##   Auxie (J6)                                      ##   Sharer                                       ##   Understudy
       ##   Candidate (J6)                                  ##   Shepherd                                     ##   Host Family
       ##   Head Moderator                                  ##   Spiritual Director                           ##
                                                                                                                             (Other - Please specify)


                                                Please 'check' one button above
            First Name:                                          Last Name:                                        Nick Name:

              Address:                                                                                                     City:

                  State:                                                    Zip:

               Home #:                                              Mobile #:                                         Other #:
                                (Please enter 10 digits beginning with the area code - no brackets, dashes, or spaces, ie 1234567890)
                  email:                                                                                            ME ... etc:
                                                                                                                                     (ME, FE, SE, YE, SPE, LSS, etc)

                    Sex:                                                 DOB:                                              Age:
                                      (M / F)                                                (mm/dd/yy)                                     (For J6 only)


                                                                 Parents / Guardians
       MALE - Parent or Guardian
            First Name:                                          Last Name:                                        Nick Name:

                Work #:                                             Mobile #:                                         Other #:
                                (Please enter 10 digits beginning with the area code - no brackets, dashes, or spaces, ie 1234567890)
                  email:                                                                                            ME ... etc:
                                                                                                                                     (ME, FE, SE, YE, SPE, LSS, etc)

                    Sex:                M                                DOB:                                  Anniversary:
                                      (Male)                                                 (mm/dd/yy)                                      (mm/dd/yy)
       ##
            Signature:                                                                                                    Date:
                                   (Please print, sign, and return a hardcopy of form to the Ministry Head)                                  (mm/dd/yy)
       FEMALE - Parent or Guardian
            First Name:                                          Last Name:                                        Nick Name:

                Work #:                                             Mobile #:                                         Other #:
                                (Please enter 10 digits beginning with the area code - no brackets, dashes, or spaces, ie 1234567890)
                  email:                                                                                            ME ... etc:
                                                                                                                                     (ME, FE, SE, YE, SPE, LSS, etc)

                    Sex:                 F                               DOB:                                  Anniversary:
                                    (Female)                                                 (mm/dd/yy)                                      (mm/dd/yy)
                                                                                                                              (same as signed copy)
            Signature:                                                                                                    Date:
                                   (Please print, sign, and return a hardcopy of form to the Ministry Head)                                  (mm/dd/yy)


                                                                                                                   FALSE
                                                                                                                     Registration                   Pending
              Electronic
       ##     CONSENT
                                                                                                                     Consent/Waiv er (J6)
                                                                                                                    FALSE                           Pending
                                                                                                                    FALSE
                                                                                                                     Pay ment
                                                                                                                     Exempt
                                                                                                                   FALSE            Pending
       (Please add any comments, suggestions, or special requests)                                                 (Official Use Only)


                                   Bukas Loob sa Diyos, Covenant Community, Archdiocese of Newark

a02270f8-94d5-44e7-b215-64a43bc4717c.xls                                           J6_App                                                                              1/25/2011
                                                              John 6 - Crossing # 11
                                                                Liebenzell Retreat Center
                                                      80 Pleasant Grove Road, Long Valley, NJ 07853
                                                                   October 22 - 24, 2010

Auxie / Sponsor Retreat Details
(1) Crossing Dates                                      From: Friday, Oct. 22, 2010                                    Drop-off time: 4:00 PM
                                                          To: Sunday, Oct. 24, 2010                                    Pick-up time: 5:00 PM

     Crossing Venue                                               Liebenzell Retreat Center
                                                                  80 Pleasant Grove Road, Long Valley, NJ 07853

     Crossing Accommodations
     Sleeping accommodations for Friday and Saturday night will at the Liebenzell Retreat Center. Male and female Auxies will be quartered in
     separate rooms (4-5 to a room). Participants should bring clothes for the weekend, personal toiletries, and towels.


(2) The cost is $55.00 for the entire weekend (includes accommodations and meals). Please make checks payable to BLD.

(3) The deadline for submission of forms and payment is Friday, October 15, 2010. Please submit an electronic version of all
     forms to boyetzita_cruz@yahoo.com as soon as possible.

(4) Auxies and Sponsors are required to attend two (2) mandatory meetings on the following dates (venue & time for both
     meetings TO BE CONFIRMED).
                  Venue                                                      Date                                                Time
     St. Mary's, Rahway, NJ                                       Saturday, Oct. 9, 2010                                  1:00 PM to 6:00 PM
     St. Mary's, Rahway, NJ                                       Saturday, Oct. 16, 2010                                 1:00 PM to 6:00 PM

John 6 Ministry Contacts:
   Boyet & Zita Cruz                             (908) 378-5182 or boyetzita_cruz@yahoo.com

     Ernest & Nellie Sun                         (908) 244-6217 or ERNEL87@yahoo.com

                  *** This is not a confirmed application unless all fully completed forms are submitted with full payment ***
           -------------------- Please cut along dotted line -------------------- Please cut along dotted line -------------------- Please cut along dotted line --------------------


Parental Consent/Waiver:
##           I do hereby give me child,                                                                 , permission to attend the John 6 Crossing Weekend Retreat
     sponsored by BLD Newark. I waive and release any and all rights and claims for damages which I may have against Bukas
     Loob sa Diyos Covenant Community and all of their agents, servants, and members, for any and all injuries which my child
     may incur while taking part in this retreat. As a parent, I understand that it is my responsibility to pick up my child at the
     predetermined time. I also understand that if my child becomes ill or disruptive, the ‘Emergency Contact’ person will be
     called to take him or her home.

Please indicate any medical concerns, conditions, and/or allergies that your child may have:
## None.
## Yes. Please explain.


Contact person in case of emergency:                                                                                 Home #                       Mobile #                      Other #
## Please check box if using the same
     contact(s) on the application form.

                                       Name:
                                       Name:

Signature (Parent or Guardian):
## I have read and agree to the terms and
     conditions as stated above.
                                                                                                                                                                                   Date
                                                                   (Please print, sign, and return a hardcopy of form to the Ministry Head)
     a02270f8-94d5-44e7-b215-64a43bc4717c.xls                                              Auxie                                                                                1/25/2011
                                                                     John 6 - Crossing # 11
                                                                Liebenzell Retreat Center
                                                      80 Pleasant Grove Road, Long Valley, NJ 07853
                                                                   October 22 - 24, 2010

Candidate Retreat Details
(1) Crossing Dates                                      From: Friday, Oct. 22, 2010                                    Drop-off time: 4:00 PM
                                                          To: Sunday, Oct. 24, 2010                                    Pick-up time: 5:00 PM

     Crossing Venue                                               Liebenzell Retreat Center
                                                                  80 Pleasant Grove Road, Long Valley, NJ 07853

     Crossing Accommodations
     Sleeping accommodations for Friday and Saturday night will at the Liebenzell Retreat Center. Male and female Candidates will be
     quartered in separate rooms (3-5 to a room). Participants should bring clothes for the weekend, personal toiletries, and towels.


(2) Candidates must be 12 to 14 years of age (or turning 12 by December 31st).

(3) Crossing is limited to the first 30 applicants (first come, first serve basis).

(4) The registration fee is $90.00 for the entire weekend (includes accommodations and meals). Please make checks payable to BLD.

(5) The deadline for submission of forms and payment is Friday, October 15, 2010. Please submit an electronic version of all
     forms to boyetzita_cruz@yahoo.com as soon as possible.


John 6 Ministry Contacts:
   Boyet & Zita Cruz                             (908) 378-5182 or boyetzita_cruz@yahoo.com

     Ernest & Nellie Sun                         (908) 244-6217 or ernel87@yahoo.com

                  *** This is not a confirmed application unless all fully completed forms are submitted with full payment ***
           -------------------- Please cut along dotted line -------------------- Please cut along dotted line -------------------- Please cut along dotted line --------------------


Parental Consent/Waiver:
##           I do hereby give me child,                                                                 , permission to attend the John 6 Crossing Weekend Retreat
     sponsored by BLD Newark. I waive and release any and all rights and claims for damages which I may have against Bukas
     Loob sa Diyos Covenant Community and all of their agents, servants, and members, for any and all injuries which my child
     may incur while taking part in this retreat. As a parent, I understand that it is my responsibility to pick up my child at the
     predetermined time. I also understand that if my child becomes ill or disruptive, the ‘Emergency Contact’ person will be
     called to take him or her home.

Please indicate any medical concerns, conditions, and/or allergies that your child may have:
## None.
## Yes. Please explain.


Contact person in case of emergency:                                                                           Home #                        Mobile #                     Other #
## Please check box if using the same
     contact(s) on the application form.

                                       Name:
                                       Name:

Signature (Parent or Guardian):
## I have read and agree to the terms and
     conditions as stated above.
                                                                                                                                                                                   Date
                                                                   (Please print, sign, and return a hardcopy of form to the Ministry Head)

     a02270f8-94d5-44e7-b215-64a43bc4717c.xls                                             Candidate                                                                             1/25/2011

				
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