PERMISSION / REQUEST FORM-2009

I __________________________________________request permission to be allowed to go on the Awakening

Retreat in Springfield IL with Catholic Campus Ministry (hereafter the "Catholic Ministry ") presently
scheduled to depart on November 5 and to return on November 7because I believe this trip will spiritually
benefit me.

I understand that all rules of conduct and standards of behavior, as deemed by “Catholic Ministry” will apply to
this trip. I further understand that I must assume all responsibility and liability for traveling to, from, and during
this trip. I also understand that it may not be financially feasible for “Catholic Ministry” to provide all
transportation for students. With this knowledge, I hereby consent to traveling to, from, and during this trip in
this manner. With this knowledge, I freely assume this responsibility and liability.

I further understand that injuries can happen. I freely accept and voluntarily assume all risks of personal injury
or death, and property damage resulting from my participation in any of the activities on this retreat.

I will not bring any alcohol or illegal drugs on this trip nor will I participate in any conduct that is inappropriate
or hazardous to the safety and moral well being of those on this retreat. I will fully cooperate with all the
regulations and guidelines of Catholic Campus Ministry.

I further understand that the “Catholic Ministry” is not responsible for any damages or accidents that may result
from my actions. To the greatest extent possible, I release the “Catholic Ministry”, and the Diocese of
Springfield in Illinois, and all those acting on their behalf, from all liability for damages to or caused to me as a
result of this trip and I agree to indemnify them for any such damages.

Emergency Contact / Medical Information: (Please Print)

Father/Guardian: _________________________________________Daytime Phone: _(____)______________

Mother/Guardian: ________________________________________Daytime Phone: _(____)______________

Address: ______________________________________________________Phone: _(____)______________

Other Contact Person: ____________________________________________Phone: _(____)______________

Insurance Co.______________________________________________________________________________

Policy Number: _______________________________

Medical Conditions/Allergies: _____________________________________________________________

Are you on any medications? List:

How often do you need to take them?