Spring Retreat Summit Lake Theme: Be May 2 nd – 4 th $40

1. Spring Retreat Summit Lake Theme:Be May 2nd – 4th $40 Make New Friends/Bring Old Friends We will leave 5pm from church parking lot, May 2nd We will return in time for the Teen Mass on May 5th I, _____________________________, hereby give my permission as the parent/guardian of ___________________________ to attend/participate in the above activity on May 2nd – 4th. I do hereby agree to release, indemnify and hold harmless the chaperones, St. Francis de Sales Church, and the Diocese of Arlington, VA, from any and all liability to any claim or injury or loss sustained by my/our child’s participation in the trip. IN CASE OF MEDICAL EMERGENCY, in the event I cannot be reached, I hereby give permission to the physician selected by the leader to hospitalize, secure proper treatment for, and order injection, anesthesia or surgery for my child. _____________________________________ ________________ Parent/Guardian Signature Date During the activity I can be reached at the phone numbers listed below ____________________________ or ____________________________ In the event I cannot be reached, please notify: _________________________ at ____________________________ / relationship ______________________. Insurance Company: _____________________________________________ Insurance Number: ______________________________________________ Cost $40 Summit Lake, Emmitsburg, MD Leave: Friday, May 2, 5:00pm Return: Sunday, May 4, In time for 6pm mass Contact Jane 703-475-0873 janedhs78@aol.com • What to bring • Warm Clothes • Sleeping bag • Pillow • Toiletries • Jacket • Shoes for • walking/hiking • Permission Slip • Bible