High School Summer Opportunities

Permission Form

Participant Name*

First Last

Date of Birth*

School*

Grade in 2025-26*

Signature of Youth Participant*

Date*

Parent/Guardian Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Primary Phone*

Parent/Guardian Secondary Phone

Parent/Guardian Email*

Secondary Parent/Guardian Email

Parental Permission and Liability Release*

As parent/legal guardian of the participant(s) named above, I give my permission to participate fully in Diocesan Kings Dominion Trip with The Basilica of Saint Mary on July 26th, 2024, from 8:00AM to 10:00PM. I agree to indemnify and hereby release the Most Reverend Michael F. Burbidge Bishop 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*

Signature of Parent/Guardian*

Date*

Payment

The cost of attending the Diocesan Kings Dominion trip is $40. If you would like a Youth Apostolate/Basilica T-shirt, there is an additional $5 fee.

Cost*

Regular Cost

Cost with Basilica t-shirt

T-Shirt Size*

Credit Card*

Cardholder Name

Card Details

Total

High School Summer 2026

High School Small Groups keep going all summer long!

Apply for Counselor

Permission Form

To be completed by the High School applicant:

ASJB College Night

Kings Dominion Day

Permission Form

Health Information

Payment

HIGH SCHOOL KICK-OFF

Questions?