Covenant & Consent Form (for ADULT PARTICIPANT - 2024)

Covenant and consent for retreat, release waiver and indemnification forms

2024 Quest- The Next Chapter

To be completed by ADULTS. Please complete the forms by October 20th and prior to coming to Cathedral Ridgel.
Adult Participant's Preferred Pronouns
where we can send you information and updates about this retreat
where we can contact you (if necessary) to obtain information related to this retreat
Is this a home, work or cell/mobile number?
Address

Photo Waiver - I give permission to use my image in the following formats:

Please donโ€™t hesitate to be specific; we fully understand that while some families arenโ€™t worried about their childrenโ€™s photos being โ€˜out there,โ€™ for others it is a serious concern and possible safety issue. We want to honor your preferences at all times.
In-house displays for participating parishes
On churches' public websites
On churches' individual FaceBook pages
On Diocesan materials including but not limited to the Colorado Episcopalian, the Diocesan website, the Cathedral Ridge website, and the Cathedral Ridge Facebook page and Instagram.

Emergency Contacts

Medical Information and Authorization

List each medication and include the condition medicine is prescribed for, the dosing amount and instructions and date and time of last dose before leaving for this retreat (ex. Metformin for Diabetes 2, 1 tablet twice a day with breakfast and dinner. Last dose taken today at breakfast):
List each medication and include the condition medicine is prescribed for, the dosing amount and instructions and date and time of last dose before leaving for this retreat (ex. Metformin for Diabetes 2, 1 tablet twice a day with breakfast and dinner. Last dose taken today at breakfast):
List each medication and include the condition medicine is prescribed for, the dosing amount and instructions and date and time of last dose before leaving for this retreat (ex. Metformin for Diabetes 2, 1 tablet twice a day with breakfast and dinner. Last dose taken today at breakfast):
List each medication and include the condition medicine is prescribed for, the dosing amount and instructions and date and time of last dose before leaving for this retreat (ex. Metformin for Diabetes 2, 1 tablet twice a day with breakfast and dinner. Last dose taken today at breakfast):
List each medication and include the condition medicine is prescribed for, the dosing amount and instructions and date and time of last dose before leaving for this retreat (ex. Metformin for Diabetes 2, 1 tablet twice a day with breakfast and dinner. Last dose taken today at breakfast):

Instructions about medications

All medications, either prescription or over the counter will be collected by your youth leader before you leave for the retreat. Please put your youthsโ€™ medications in a zip lock bag clearly marked with their name and give them to your youth leader before they leave. Upon arriving at Cathedral Ridge, all medications will be collected by our trip nurse and kept in a secure location. Each day youth will come to the nurse to take their medications. A log will be kept of all medication taken by the youth.

IF YOU START A NEW MEDICATION BETWEEN NOW AND THE RETREAT, PLEASE MAKE SURE WE KNOW ABOUT THE NEW MED, HOW AND WHEN TO DISPENSE IT, AND ANY POSSIBLE SIDE EFFECTS IT COULD CAUSE, THANKS!

Emergency Room or Urgent Care

In the event of an emergency, I understand that every effort will be made to contact my emergency contact as soon as possible, and that efforts to contact my emergency contact will continue even as care or treatment is administered. If needed, which is your preference: Urgent Care or Emergency Room. An effort will be made to meet this request if possible.
Please make a selection:

I hereby authorize the adult leader(s) named below to act as agent for me and to seek and consent to any medical, dental, or surgical evaluation and treatment deemed necessary by a licensed medical professional.

Insurance

Participant's Name
Include: Name of Company, Policy # Street Address, City/State/Zipcode, Name of Policyholder Group #

Please provide a photocopy of your insurance ID card.

Signature Page

Your Name(Required)
MM slash DD slash YYYY
Name