I request that the Roman Catholic Diocese of San Jose, Office of Youth and Young Adult Ministries, permit my child to participate on the Life Teen Retreat to be held at Mount Hermon Conference Center on November 17-17, 2019. I understand that reasonable precautions will be taken to safeguard the health and well being of my child, and that I will be notified as soon as possible in the event of an emergency. In case of sickness or accident, I authorize and consent to any x-ray exam, anesthetic, medical, dental or treatment and hospital care to be rendered to my child under the general care and advice of any physician, dentist or surgeon licensed to practice in any state. I further understand and agree to be responsible for any such medical, dental and/or hospital expenses incurred.

I understand and agree to direct my child to follow all rules and guidelines including any dress codes. I understand the consequences of my child violating or disrespecting and of these rules.

I hereby grant permission for my child to be photographed and/or videotaped during the event/activity. I understand that my child may decline to be photographed and/or videotaped at any time. I further grant permission for the resulting photographs and/or videotaped footage to be edited, if necessary, and then published and/or broadcast for the purpose of promoting the Holy Family Life Teen and Edge ministries.