About

All high school students are invited to join us for a line dance in celebration of the parish’s 230th anniversary with other local parishes!

• WHEN: Friday, February 21st, 2025 from 7PM to 9PM
• WHERE: Lyceum Auditorium, 313 Duke Street, Alexandria, VA 22314
• WHAT: a line dance for all high school students of Alexandria and beyond in celebration of the parish’s 230th anniversary!
• DRESS CODE:
  • Ladies: 
    • skirts/dresses need to be at least knee length
    • please no low V-neck shirts/sweaters
    • Please make sure your blouse/sweater covers your midriff when you lift your arms.
  •  Gentlemen:
    • Nice jeans or slacks
    • Tucked in shirt

PLEASE REMEMBER TO FILL OUT THE PERMISSION FORM BELOW TO ATTEND!

Permission Forms

"*" indicates required fields

Permission Form

Participant Name*

First Last

Date of Birth*

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Parent/Guardian Name*

First Last

Address*

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Parent/Guardian Primary Phone*

Parent/Guardian Secondary Phone

Parent/Guardian Email*

Safety

As the participant, I agree to follow all procedures, safety precautions, and rules and regulations set forth by the Diocese and the Parish.

Signature of Youth Participant*

Date*

MM slash DD slash YYYY

Parental Permission and Liability Release*

As parent/legal guardian of the participant named above, I give my permission to participate fully in the Basilica of Saint Mary's High School Line Dance on February 21, 2025 from 6:00p.m. to 8:00p.m. at the Basilica of Saint Mary's Lyceum Auditorium, 313 Duke Street, Alexandria, VA, 22314. I agree to indemnify and hereby release the Most Reverend Michael F. Burbidge of the Catholic Diocese of Arlington and his successors in office, as well as the Catholic Diocese of Arlington and all Diocesan clergy, employees, volunteers, and participating parishes and schools from any and all liability, claims, demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned of the participant resulting from said participant’s involvement in the above mentioned event (including transportation to and from the event). Furthermore, I on behalf of the participant hereby assume all risk of personal injury, sickness, death, damage, and expenses resulting from said participant’s involvement in the above-described event.

Informed Consent to Medical Treatment:*

I request that in my absence the above-named minor be admitted to any hospital or medical facility for diagnosis and treatment when a condition or injury arises that is serious enough that a reasonable person would seek care right away. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor. I assume full responsibility for all costs of such treatment. Further, should it be necessary for the participant to return home due to medical, disciplinary, or other reasons, I do hereby assume responsibility for the participant’s transportation home and any costs related thereto.

Photo, Press, Audio, and Electronic Media Release:

I authorize the Catholic Diocese of Arlington, its parishes, its schools and/or the Arlington Catholic Herald to use and publish my child’s photograph, video and/or audio recording along with their name identifying them for educational, news stories, illustration and/or marketing purposes.

Health Information

Primary Health Provider*

Phone Number*

Insurance Company*

Policy Number*

Emergency Contact Name*

First Last

Relationship*

Phone Number*

Known allergies (including any allergies to medicine)*

Any other medical problems which should be noted*

Consent*

I understand and hereby agree to the terms and conditions of the participant’s involvement in the above described event and I freely execute this Acknowledgement with full knowledge of its content.

Signature of Parent/Guardian*

Date*

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YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

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Location

Questions?

Please contact Mrs. Mariane Staron at mstaron@stmaryoldtown.org.