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Spring Retreat Summit Lake Theme: Be May 2 nd – 4 th $40 Make New Friends/Bring Old Friends We will leave 5pm from church parking lot, May 2 nd We will return in time for the Teen Mass on May 5 th I, _____________________________, hereby give my permission as the

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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