NAME ________________________________________            AGE____           GRADE _____

PARISH: St. Madeleine Sophie CITY/STATE: Guilderland, NY            (Please circle) Male Female

Parent/Guardian (Please type or print.)

I, __________________________ [parent ( ), legal guardian ( ) ], the undersigned, give my permission for my
son/daughter to attend The Confirmation Retreat Weekend at Camp Pinnacle, 7pm, Friday, November 7 - 2pm,
Sunday, November 9, 2008, and if needed, to be evaluated, diagnosed, treated and/or medicated in accordance with
standard medical practice by licensed medical personnel. I relieve the parish of St. Madeleine Sophie and the
leadership personnel of this event of all responsibility and consequences that may arise as the result of this treatment.

I will not hold St. Madeleine Sophie parish or site leadership personnel responsible in the event of injury or illness.
Further I agree to abide by all rules and regulations decided upon by St. Madeleine Sophie parish and the leadership
personnel of the event. I understand that neither the parish of St. Madeleine Sophie nor the leadership personnel of
the event will be held liable if my child fails to cooperate with said regulations and that any infractions of the rules
may result in immediate dismissal from the event. I further understand that I will be responsible for any costs or
other requirements for immediate transportation home or for damages incurred by my child.

__________________________________                               _________________________

Signature of Parent or Guardian                                                               Date

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                                                 Use reverse side or attach additional pages, if necessary.

Allergies________________________________________

Required medications (please indicate dosages, frequency, etc.) ______________________________

Special medical conditions: ______________________________

Insurance Carrier _________________________  Policy carrier   _________________________

Policy number ____________________             Date of last tetanus booster ___________________

In case of emergency and I cannot be reached, please notify ______________________________

Relationship to youth ______________________________ phone # ____________________

I will be away during that period of time, but I can be reached at (name, address, phone)

_____________________________________________________________________

Signature of Parent or Guardian ______________________________ Date _________________

Address _____________________________ City ________________, NY        Zip _______

Phone ___________________________ Cell phone ___________________________

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                                  YOUTH & PARENT/GUARDIAN PARTICIPATION AGREEMENT

PARENT/GUARDIAN:

My child agrees to abide by all rules and regulations as stated by Camp Pinnacle, St. Madeleine Sophie Parish, and
the Albany Diocese. No drugs, alcohol, or unruly behavior will be engaged in during this activity. If such incidents
occur, I understand my child will be immediately dismissed from the event, and I will be responsible for arranging
transportation home.

____________________________ _______________________

Parent/Guardian Signature                                  Date

YOUTH:

I, _____________________, understand and agree to follow the rules and regulations presented by St. Madeleine
Sophie Church and Camp Pinnacle. I will not engage in drug or alcohol use prior to or during the event, and will
behave responsibly. I understand that neither the parish of St. Madeleine Sophie, nor the leadership personnel of
Camp Pinnacle will be held liable if I fail to cooperate with said regulations, and that any infraction of rules may
result in my immediate dismissal from this event. Should this occur, I understand that my parent(s)/guardian(s) will
be held responsible for my transportation home, and any additional costs incurred. I will remain in attendance at
the conference site until my parent(s)/guardian(s) arrives to bring me home.

_____________________________ _________________________

Youth Signature                                           Date