High

School Retreat 2014

Grades 9th -12th

November 7-9
St. Pauls-on-the-Plains, Lubbock, TX
Cost:

Registration fee is $60 if postmarked by October 15th

Registration fee is $80 if postmarked after October 15th

Check in and out:

Check in will begin at 7:30pm on Friday, November 7th at St. Pauls, 1510 Ave X, Lubbock
In case of delay or last minute cancellation, please call Renee Haneys cell phone (806) 445-3667
All participants are to be picked up at 12:30 p.m. on Sunday, November 9th join us for light lunch
Please wait in Fellowship Hall if you arrive early
What to bring: Sleeping bag, air mattress, toiletries, towel, swimsuit, comfortable clothes (please bring extra set
of work clothes (jeans, t-shirt, closed toe shoes), attitude for fun
Cell Phone and Electronics Policy: All youth are asked to leave phones and other electronic devices at home
Emergencies: In the event you need to reach a participant due to an urgent matter or emergency, please call
Renees cell phone (806) 445-3667
Visitor Policy: VISITORS WILL NOT BE ALLOWED DURING RETREATS! This includes parents or social
visits from family or friends. This is for the safety of the youth and sponsors.

2014 Mission Blast Registration

Participant Information (PLEASE PRINT CLEARLY)
Full Name

____________________________________________________________________________
Last
First
Middle

Name to appear on nametag (if different from legal name) ________________________________________

Address _______________________________________________________________________________
City ____________________________________ State ________________ Zip _____________________
Age __________ Current Grade __________ Date of Birth _____________________ Gender M

Participants email _________________________________________________________________________

Camper T-Shirt Size- all are adult sizes (circle one):

XL

XXL

Fathers Name ________________________________

Home Phone _____________________________

Father's email: ________________________________

Cell Phone _______________________________

Mothers Name _______________________________

Home Phone _____________________________

Mother's email: _______________________________

Cell Phone _______________________________

Home Church ____________________________________ City ___________________________________

Alternate Contact (in case parent/guardian cannot be reached) _____________________________________
Relationship _______________________________Phone ________________________________________
Please make checks payable to Diocese NWTX Youth or you may pay by credit card by completing the
following information (you will receive an email with instructions for paying online via PayPal)
Name as it appears on credit card: ______________________________________________________________
Amount ______________________

Mail or Fax to: Diocese of Northwest Texas, Youth Office

1802 Broadway
Lubbock, Texas 79401
Fax (806) 762-8986
Questions: Please contact Renee Haney, Diocesan Youth Coordinator at: (806) 445-3667 or email at nwtxyouth@suddenlink.net

Diocese of Northwest Texas Youth Code of Behavior:

Adherence to the Code of Behavior is required from everyone who is a part of the
youth program and participating in youth events:
I will treat everyone with respect and dignity.
I will not use inappropriate language during my stay.
I understand that each person has physical boundaries and I will not step over their boundaries.
I understand that sexual misconduct is unacceptable with the youth, counselors and sponsors and will
not be tolerated. This includes sexual harassment, jokes containing sexual material or sexual
conduct.
I understand that the use of alcohol, illegal drugs and tobacco products are prohibited during my stay.
I will treat others, as I would expect to be treated.
I will treat the facilities with care and not abuse the property.
I will respect all of the wildlife and recognize that this is their home.
I will have a positive attitude and encourage everyone to do the same. 
By signing below, I agree that these are reasonable expectations and I will do everything I can to live up to
them. If I choose to violate the rules set for the event I am planning to attend, I understand that there will
be consequences, which may include my being sent home.
Participant Signature: ___________________________________

Date: _______________

As parent and/or legal guardian of this child I have read the above and believe that he/she is capable of
aspiring to and following these community expectations and rules.
Parent Signature: _____________________________________

Date: _______________

Photo/Video Publicity Release Statement

The undersigned participant does agree to grant the Episcopal Diocese of Northwest Texas permission to
record on film, videotape, or audiotape, his or her participation in Mission Blast 2014 for publicity purposes.
He or she further agrees that any or all of the material recorded may be used, in any form, as part of any
future publicity media made by the Diocese of Northwest Texas Youth Program, and further that such use
shall be without payment of fees, royalties, special credit, or other compensation.
_________________________________________
Parent/Guardian Signature



Questions: Please contact Renee Haney, Diocesan Youth Coordinator at: (806) 445-3667 or email at nwtxyouth@suddenlink.net

Health Information & Emergency Treatment Release Form

Please Print Clearly

Camper Name _____________________________________________________________________

Age _______

DOB __________________

Physicians Name _________________________________________ Phone # _________________

Insurance Company _________________________________ Phone # ________________________
Group/Plan # ________________________________ Member # _____________________________
(Copy of insurance card is helpful but not mandatory)
Any restrictions on activities? __ If so, please list ? ________________________________________
Any dietary restrictions or allergies? __ If so, please list: _____________________________________
Any allergies to medications? __

If so, please list: ________________________________________

Please list any other information that would be helpful in making this youth event successful for your
youth: _____________________________________________________________________________
___________________________________________________________________________________
OTC Medication Consent: I give permission for the adult sponsors to administer OTC medication such
as ibuprofen, Tylenol, cough drops, etc., as needed to my child. Parent Initial :__________________
Medications to be administered at the youth event- Please note that medication must be in original bottle
with dosage. If sending OTC medication, please write youths name on bottle with dosage.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
My child is healthy and capable of participation in this event without causing risk of danger, illness, or
accident to him/herself or to others. I agree to hold harmless the leaders of my church, Diocese of NWTX
staff, volunteers, the Bishop of Northwest Texas and the Episcopal Diocese of Northwest Texas in the event
of injury or accident. I declare that my child is covered by medical insurance and/or I am responsible for any
and all expenses incurred by my child whether covered by insurance or not. In the event that my child
requires medical or dental attention, I understand that an adult sponsor will make every attempt to contact
me. In the event that I cannot be reached, I consent to any medical attention deemed appropriate. In the
event treatment is called for where the medical provider refuses to administer without my consent, I hereby
authorize an adult sponsor to give such consent for me if I cannot be reached immediately or because of
emergency there is no time or opportunity to make contact. In the event that it is necessary for that person
to give consent, I agree to hold such person free and harmless of any liability for damages arising from
giving such consent.
Parent/Guardian Signature ________________________________________________ Date________________________

Please return completed forms and payment to: Diocese of Northwest Texas, Youth Office, 1802 Broadway, Lubbock Tx 79401 Fax (806)762-8986

Questions: Please contact Renee Haney, Diocesan Youth Coordinator at: (806) 445-3667 or email at nwtxyouth@suddenlink.net