2026 Quo Vadis Retreat for Highschool Students

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Section: Participant Information
Full Name of Participant:
Date of Birth:
Email Address of Participant:			Email Address ([email protected])
Primary Phone Number of Participant:			Phone Number (xxx-xxx-xxxx)
High School Grade Level:
Dietary Restrictions:
Home Parish:		Please select a home parish
If other, then please enter the parish name
Home Address:		Please provide a home address
City:
State:		Please select state
Zip code:		Please provide your mailing zip code
Section: Parent/Guardian Information
Parent/Guardian Name:		Please provide the parent/guardian name
Relationship:
Cell Phone:			Phone Number (xxx-xxx-xxxx)
Email Address:			Email Address ([email protected])
Secondary Contact Name:		Please provide a secondary contact name
Relationship:
Cell Phone:			Phone Number (xxx-xxx-xxxx)
Email Address:			Email Address ([email protected])
Section: Youth Medical Waiver
In the event of an emergency, I hereby give permission for my youth to be taken to a physician or hospital by an adult youth leader, diocesan staff member, or parish personnel. I understand that every effort will be made to contact me. However, if I cannot be reached, I hereby give permission to the responsible physician to hospitalize and secure proper treatment, including surgery, for my youth.	Please check the box
I hereby grant permission for a staff person to provide the following over-the-counter drugs to my youth if necessary. (Please note that category of medicine and example are listed, though a different brand may be used.) Doses are not to exceed manufacturer’s recommendations.
Over-the-Counter Drugs	Acetaminophen (Tylenol) Ibuprofen (Advil) Naproxen (Aleve) Antihistamine (Benadryl) Cough Relief (Robitussin) Antacids (Tums/Rolaids) Topical Antibiotic (Neosporin) Allergy Relief (Claritin/Zyrtec)
Medical Insurer:		Please provide the medical insurer
Policy Number:		Please provide the policy number
Please list any allergies, dietary restrictions, or medical conditions:
Please list any prescription medications that participant is taking, along with dosage information, time of day, and any additional instructions. (If none, leave blank. All medications will be dispensed by adult coordinators, unless parent/guardian explicitly directs otherwise.):
I have reviewed the medical information above; to the best of my knowledge it is accurate and complete. If there is any change to the physical status of my youth, I will inform the event coordinators immediately.
Electronic Signature:		Please provide an electronic signiture
Date:		Please select today's date
Section: Photography/Video Disclaimer
I understand that photos/videos may be taken of participants during this event. The media may be used in publications, websites, or other materials by the Diocese of Raleigh. Participants will not be identified without specific written consent. Parents/guardians who do not wish their children to be photographed or filmed should please notify the Diocese of Raleigh in writing.	Please read and check the box
Section: Parent Guardian Authorization and Release of Liability
I hereby consent to the participation of my youth in the Quo Vadis Retreat and understand that it is an off-site event requiring transportation to Camp Dixie in Fayetteville, North Carolina. I agree that I remain fully responsible for any liability which may result from personal actions taken by my youth, and that he may not be in possession of drugs, alcohol, tobacco products, weapons, or firearms of any kind. I consent that my youth must comply with all directions given by staff or volunteers during the course of the event, and that any illegal, immoral, or offensive behavior will result in my youth’s immediate dismissal, for which I will be required to provide transportation from the site. I hereby release the Diocese of Raleigh, its constituent parishes, and all of its agents and volunteers, from any injuries or illnesses which may be incurred by my youth.
Electronic Signature:		Please enter an electronic signiture
Date:		Please select today's day

Item(s)	$0.00

Grand Total	$0.00

2026 Quo Vadis Retreat for Highschool Students

Description

The Quo Vadis Retreat is a young men retreat for High school students that want to grow closer to God.

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