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Ablaze High School Youth Group
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Immaculate Heart of Mary/Pope John Paul II
353 S. Pagosa Blvd
Pagosa Springs, CO 81147
970-731-5744
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Ablaze High School Youth Group
September 2024 - August 2025 General Consent
Diocese of Pueblo Youth Permission/Release of Liability
The maximum number of form submissions has been reached. This form is currently not available.
This form is for general consent from the parent or legal guardian to allow their high schooler to attend Ablaze High School Youth Group gatherings in Pagosa Springs. Special events or out of town gatherings may require an addendum form to be signed.
All participating youth are required to have a completed form on file.
Form to be completed by Parent or Legal Guardian.
Email
[email protected]
with questions.
Teen (Minor) Participant
First Name
REQUIRED
Please fill out this field.
Please enter valid data.
Last Name
REQUIRED
Please fill out this field.
Please enter valid data.
Nickname (optional)
Please enter valid data.
Birthdate
REQUIRED
Please fill out this field.
Please enter a date.
Age
REQUIRED
Please fill out this field.
Please enter an integer (number).
Teen Phone Number
Maximum 20 characters
Please enter a phone number.
Teen Email
Please enter an email address.
Grade (Must be in High School!)
REQUIRED
(Select One)
9th Grade - Freshman
10th Grade - Sophomore
11th Grade - Junior
12th Grade - Senior
Please fill out this field.
Parent/Legal Guardian Permission to Participate (Required)
I give permission for my child, named above, to attend ABLAZE High School Youth Group gatherings hosted by Immaculate Heart of Mary/Pope John Paul II.
I understand that the teachings will be founded on Catholic Doctrine and that any High Schooler, regardless of religion, may participate.
I Give Permission
Please select this field.
I, the parent or guardian of the teen named above, remain legally responsible for any personal actions taken by the above-named minor (“participant”). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend the Diocese of Pueblo and/or Immaculate Heart of Mary / Pope John Paul II, its officers, directors, employees and agents, and the Diocese of Pueblo and/or its employees and agents, chaperones, or representatives associated with ABLAZE High School Youth Group events, from any claim arising from or in connection with my child’s participation or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the Diocese of Pueblo, Immaculate Heart of Mary / Pope John Paul II, its officers, directors and agents, chaperones, or representatives associated with the events for reasonable attorney fees and expenses with may incur in any action brought again them as a result of such injury or damage, unless such claim arises from the negligence of those list herein.
I Agree and Understand
Please select this field.
Primary Parent/Guardian Information
First Name
REQUIRED
Please fill out this field.
Please enter valid data.
Last Name
REQUIRED
Please fill out this field.
Please enter valid data.
Relationship to Minor
REQUIRED
(Select One)
Mother
Father
Guardian
Please fill out this field.
Phone Number
REQUIRED
Maximum 20 characters
Please fill out this field.
Please enter a phone number.
Email
REQUIRED
Please fill out this field.
Please enter an email address.
Do you give permission for your teen to receive email/text updates about Ablaze?
REQUIRED
Yes
No
Please fill out this field.
Physical Address
REQUIRED
Please fill out this field.
Please enter valid data.
City
REQUIRED
Please fill out this field.
Please enter valid data.
State
REQUIRED
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Please fill out this field.
Zip
REQUIRED
Please fill out this field.
Please enter a zip code.
Mailing Address (if different than physical address)
Please enter valid data.
Secondary Parent/Guardian Information (If applicable)
First Name
Please enter valid data.
Last Name
Please enter valid data.
Relationship to Minor
None
Mother
Father
Guardian
Phone Number
Maximum 20 characters
Please enter a phone number.
Email
Please enter an email address.
Would you like to be copied on emails?
Yes
No
Emergency Contact
EMERGENCY MEDICAL TREATMENT
:
In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor.
I Agree
Please select this field.
In the event of an emergency,
if you are unable to reach me
at the above numbers, contact:
First Name
REQUIRED
Please fill out this field.
Please enter valid data.
Last Name
REQUIRED
Please fill out this field.
Please enter valid data.
Relationship to Minor
REQUIRED
(Select One)
Grandparent
Family Friend
Neighbor
Other Family Member (Aunt, Uncle, Cousin, etc.)
Other
Please fill out this field.
Phone Number
REQUIRED
Maximum 20 characters
Please fill out this field.
Please enter a phone number.
Medical Matters
OTHER MEDICAL TREATMENT:
In the event it comes to the attention of the parish, its officers, directors and agents, and the Diocese of Pueblo and/or Immaculate Heart of Mary/Pope John Paul, chaperones, or representatives associated with the activity, that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, you will be contacted as soon as it is reasonably possible.
To the best of my knowledge my child is in good health.
REQUIRED
Yes
No
Please fill out this field.
If you answered no above, please explain.
My child IS TAKING medication at present.
REQUIRED
Yes
No
Please fill out this field.
If you answered yes above, provide names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage.
Select one of the following:
REQUIRED
No medication of any kind may be administered to my child unless the situation is life threatening and emergency treatment is required.
I grant permission for non-prescription medication (i.e. non-aspirin products such as ibuprofen, antacids, acetaminophen, etc.) to be given to my child, if deemed appropriate.
Please fill out this field.
S
PECIFIC MEDICAL INFORMATION:
The parish will take reasonable care to see that the following information will be held in confidence.
Allergic reactions (medications, foods, plants, insects, etc.):
REQUIRED
Please fill out this field.
Please enter valid data.
Does child have a medically prescribed diet? (If yes please explain.)
REQUIRED
Please fill out this field.
Please enter valid data.
Does child have any physical limitations?
REQUIRED
Please fill out this field.
Please enter valid data.
Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, bedwetting, fainting?
REQUIRED
Please fill out this field.
Please enter valid data.
Are there any other special medical conditions for this teen?
Please enter valid data.
Doctor and Insurance Information
Family Doctor
REQUIRED
Please fill out this field.
Please enter valid data.
Family Doctor's Phone Number
REQUIRED
Maximum 20 characters
Please fill out this field.
Please enter a phone number.
Family Health Plan Carrier
Please enter valid data.
Policy Number
Please enter valid data.
E-signature: To the best of my knowledge the above medical information is accurate, and I assume all responsibility for the health of my child.
Please select this field.
E-signature: My child will bring all such medications necessary and such medications will be well-labeled. I understand that my teen will not be allowed to bring or take any medication, prescribed or otherwise, not listed or given permission here.
Please select this field.
Photographic and Video Release
From time to time, pictures and videos may be taken of Ablaze ministry events and gatherings. We would like to be able to use the photographs and videos for flyers, parish and diocesan publications, and the ministry website. Written consent by parent/guardian is required.
Names will not be posted unless
written authorization is given and then only first names will be used. If there are concerns about pictures or videos posted on the website, please contact the ministry coordinator or webmaster, and they will promptly be removed.
Option 1:
I / We, the parent(s) / guardian(s) of the youth named above, authorize and give full consent, without limitation or reservation to Immaculate Heart of Mary / Pope John Paul II Catholic Church photograph or video in which the above-named student appears while participating in any program associated with Immaculate Heart of Mary / Pope John Paull II Catholic Church ministry. There will be no compensation for use of any photograph or video at the time of publication or in the future.
Option 2:
I / We, the parent(s) / guardian(s) of the youth named above,
DO NOT GIVE
authorize or consent to Immaculate Heart of Mary / Pope John Paul II Catholic Church to photograph or video above named student while participating in any program associated with Immaculate Heart of Mary / Pope John Paull II Catholic Church ministry.
Photographic and Video Release
REQUIRED
Option 1: I give consent
Option 2: I DO NOT give consent
Please fill out this field.
Youth Code of Conduct
Diocese of Pueblo / Immaculate Heart of Mary / Pope John Paul II
Youth Code of Conduct
Youth participants will:
Project an image of Christian consideration, sensitivity, and respect to everyone and to the property around them through language, dress, and behavior. (Note: Prohibited attire includes short shorts, tank tops, any clothing with inappropriate writing/images, exposure of mid-drift or undergarments, or any reference to profanity, tobacco or alcohol products including insignias or advertisements.)
Refrain from inappropriate touching and verbal harassment.
Respect the property of others (public, private, personal).
Refrain from actions that could result in injury and/or damage to property.
Adhere to stated curfew, remain as a group and refrain from being a click among selected peers.
Attend all scheduled activities, arriving promptly, and staying for the entire event.
Act as a lady or gentleman and refrain from any sexual misconduct.
Behave in a manner consistent with the spirit of the event or activity.
Respect all adult leaders, teens, and others present in action and in words.
Report problems of any kind to a trusted adult chaperone.
Adhere to rules related to cell phone/electronics usage, as set by the trip leaders/adult chaperones.
Follow all rules set by the trip leaders/adult chaperones.
Youth participants will not:
Possess weapons of any kind.
Purchase, possess, consume, or distribute alcohol.
Purchase, possess, consume, or distribute illegal drugs.
Purchase, possess, distribute, or use nicotine or marijuana of any kind, including vaping/e-cigarette products.
Enter an area/room that is designated for the opposite gender (i.e. girls cannot enter a boy’s sleeping area or vice versa).
Engage in any form of sexual activity or peer sexual harassment.
Purchase, download, possess, view, or distribute pornography.
By checking the E-signature below, I agree that my teen will abide by the Youth Code of Conduct.
They
realize and agree, that if they do not abide by these rules, they will lose the privilege of attending a scheduled activity and could be sent home at the discretion of the adult leaders
at my (parent’s or guardian’s) expense
. I understand that personal belongings of my teen are subject to random checks by adult chaperones, and I will be responsible for all consequences of their behavior.
E-signature
Please select this field.
Confirmation of Registration Email will be sent to:
REQUIRED
Please fill out this field.
Please enter an email address.
Submit
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