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SYNERGY REGISTRATION
Office for Youth Ministry
Dear Parish Leader,
First of all, we appreciate you joining us for SYNERGY 2015. The theme for this year is VICTORIOUS! We pray
this event will bring you and your group closer to Christ. Enclosed you will find:
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Registration Instructions
Synergy Code of Behavior
Synergy Chaperone Responsibilities (due back to our office)
Registration Form (due back to our office)
Description of Workshop Presenters
Parental Consent Form and Liability Waiver (to be kept with you)
(Available in English and Spanish)
Instructions:
Please include all youth and chaperones in the Registration Form. Parental Consent Forms must be filled out for
every minor attending and should be kept in your possession. We need every chaperone to read and sign the
responsibilities form (turn into OYM office). This year we will be offering 5 workshops during 2 separate time slots,
please select the top 3 presenters for your group. Your group will be assigned to attend one workshop for one of
the time slots and will get to spend time in our outdoor thematic park during the other time slot. The cost for the
event is $30.00 per person. All registration forms are due back in our office by no later than March 11th (for the
early rate to apply). After March 11th forms will be accepted at $35.00 per person. No registrations will be
accepted after March 25th. No refunds will be given after March 25th. Food is not included in the price. You
have the option of purchasing dinner combos ahead of time (in your registration). Combo #1 ($4) will include 1
hotdog, chips, cookie and a bottle of water. Combo #2 ($5) will include 2 hotdogs, chips, cookie and a bottle of
water; if your group would prefer to have something different for dinner please make the appropriate
arrangements. There are many restaurants nearby that can deliver food. Be aware that youth are not allowed to
leave Mater Dei Catholic High School during Synergy. Food will also be available for purchase onsite but only
during lunch time.
Once the registration forms have been received, we will have an additional packet for you with wristbands and
additional details for Synergy.
We look forward to a successful and spirit filled day!
Thank you,
The Youth Office
Synergy
Code of Behavior
We are happy and excited that you are joining us as part of Synergy 2015. The Code of Behavior has been developed
as a way of helping participants understand what is expected of them. The following rules of conduct will help our
event go smoothly and ensure the safety of all participants. Please read and sign the form with your parents and
return it to your Youth Minister.
1. As necessary as rules are to maintain order, they can't and won't guarantee a successful Synergy experience.
Success depends on people's willingness to work together for the common good.
2. Participants take part in Synergy as part of a parish or school team. The adult leader of each team maintains
primary responsibility for the actions of his or her team members. The sponsoring parish and the families
of team members assume responsibility for any damage done to the facilities.
3. Participants are expected to attend all sessions unless explicitly excused by the Program Director.
4. Wristbands should be worn during all program activities.
5. Dress for Synergy is casual; however shirts and shoes must be worn at all times. No short shorts, halter tops,
tube tops, or sagging pants, modesty is important. Please keep undergarments under your garments.
6. Socializing should take place only when permitted.
7. Be respectful of your surroundings. Surroundings include people, property, motor vehicles, etc.
8. No fighting, weapons, fireworks, lighters, or explosives are permitted.
9. The purchase, possession or consumption of alcohol or drugs by participants will result in immediate
dismissal from the program. Major infractions of the Code of Behavior will meet with the same consequences.
I have read and understood this code of behavior and I agree to abide by the rules above. I understand that
failure to comply with the code may result in my dismissal from the event.
__________________________________
(Teen Participant)
________________
Date
__________________________________
(Parent/Legal Guardian)
________________
Date
CHAPERONE RESPONSIBILITIES
SYNERGY YOUTH RALLY
Group Leaders and Chaperones must read, understand, agree, sign and return this form with their liability forms. Please be
sure that the Group Leader, the adult chaperones and your youth understand and abide by these policies.
Basic Role of Chaperones:
 Chaperones must be 21 years of age or older, of good moral character and judgment.
 Chaperones must meet the requirements of their local diocese for working with youth, and by signing this form agree
to comply with their local Diocesan Child Protection/Safe Environment Policies.
 For the safety and well-being of all conference participants and volunteers, the Diocese of San Diego-Office for
Youth Ministry, depends on the adult example of obedience and cooperation with the policies and procedures as
well as with our staff and volunteers on site.
 Chaperones should feel comfortable directing, sharing, and praying with their youth.
 Youths must be accompanied by a chaperone at all times.
 In case of an emergency contact your parish youth minister.
Detailed Chaperone Responsibilities: Including, but not limited to the following:
Appropriate Dress
 All participants are expected to dress in a fashion that represents modesty and good taste, respecting other
participants and our Lord. Clothing must cover all undergarments and midriffs.
Conduct
 It is expected that youth and adults will follow the directions of ALL Synergy Staff, Security, and Volunteers. Any
instances of lack of cooperation or insubordination will not be tolerated and will be subject to appropriate discipline.
All discipline problems regarding teenage participants will be brought to the attention of their Group Leader.
Drugs, Alcohol and Weapons
 All alcohol, drugs and weapons are prohibited from Synergy. All state and local laws concerning alcohol, drugs and
weapons will be strictly enforced. Violators will be subject to appropriate discipline and legal procedures.
Guests
 Only registered participants are allowed to participate in Synergy. No guests are allowed.
Health Issues
 In the event of a medical emergency, contact your parish youth minister for immediate assistance. For nonemergency medical needs, all participants will be directed to Synergy’s First Aid Center. This center is available
during Synergy’s event hours. Any special needs should be reported on the participants waivers and again prior to
check in to any diocesan staff.
Ministry
 The primary role of the chaperone is to minister to the teens. This cannot happen if you are not with them. As a
chaperone you must accompany your teens at all times.
 Adults should not take youth off site, except in the case of emergency.
I,______________________________________ (Chaperone), have read, understand, and agree to the above policies. I will
support the regulations and policies stipulated for Synergy. I certify that I meet the standards and requirements of my diocese
for working with minor age youth.
________________________________________
Adult Chaperone Signature
____________________________
Date
Synergy Registration Form
Saturday April 11th, 2015
Mater Dei Catholic High School
Diocese of San Diego - Office for Youth Ministry
THERE IS NO REGISTRATION THE DAY OF SYNERGY
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A maximum of 10 youths can be registered per 1 paid adult chaperone.
Registration fee is $30 per person until March 11th. $35 thru March 25th - Food not included
No registrations will be accepted after March 25th.
Full Payment is due April 25th.
Mail all Checks payable to:
Office for Youth Ministry, P.O. Box 85728, San Diego CA. 92186-5728
5. No refunds will be available after March 25th
6. Optional Dinner Coupons can be purchased - $4 or $5 combo
7. Questions call 858-490-8260, fax 858-490-8272, or e-mail [email protected]
Please Print Clearly
Diocese _______________________________________________________________________
Parish ________________________________________________________________________
School/ Org. ___________________________________________________________________
City___________________________________________________ State __________________
Contact Person: (if attending please include yourself below where applicable)
Name ____________________________________________ Day Phone (___) ____________
Address __________________________________________ Eve. Phone (___) ____________
City ___________________________________ State ______________ Zip _______________
Email ________________________________________________________________________
Adult Chaperone:
____________________________________________________
First Name
Last Name
Registrants (print clearly: check if Adult)
Adult
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Youth
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First Name
_ $30
$35__
Thru
Mar. 11
Mar. 11March 25
Last Name
$60
$90
$120
$70
$105
$140
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$150
$180
$210
$175
$210
$245
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$240
$270
$300
$280
$315
$350
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$330
$385
Workshop Choice for Group:
1st_____________
2nd ____________
3rd ____________
# of Dinner Combos
$4 Combo: _______
Waiver Certification:
I hereby certify that all youth participants have submitted the required waivers,
$5Combo:________
_____________________________
Signature of Parish Representative
Total Cost: _______
______________________________
Printed Name of Parish Representative
SYNERGY PRESENTER LIST 2015
(A) PRESENTER: Jamie Cleaton
Jamie Cleaton is a local San Diegan who has been led on numerous adventures spanning the
globe and now uses those experiences and his passionate speaking to invite young people
into the greatest adventure, that of following Christ into fullness of life. Jamie has been
active in youth ministry for 10 years and has been speaking professionally since 2008. He
has been blessed to speak to thousands of high schoolers and young adults all across the
United States
(B) PRESENTERS: Jeremy and Ryan
Jeremy and Ryan have been recognized as one of the best up and coming
Catholic Rock artists today. They are very humbled by the gifts and
opportunities that God has given them, and they are excited about what the
future holds.
(C) PRESENTER: Briana Robell
Ralph Waldo Emerson said, “To be yourself in a world that is constantly trying to make
you something else is the greatest accomplishment.”
In life, we have two worlds to figure out: the Work World and the Social World. In the
Work World it’s all about grades, classes, and career. In the Social World it’s all about
friends, family, love interests, parties, and sex.
As a singer and pianist, Bri opens with secular music and reveals a method that will help
you discover your uniqueness in a world that’s constantly trying to make you something
else. Bri creates a down-to-earth, judgment-free zone that gives clarity when it comes to
choosing what’s most beneficial in the Social World. To hear and read more check out
Bri’s website at www.brianarobell.com
(D) PRESENTERS: Love Resonate
Love Resonate is dedicated to making the love of Christ resonate within
the hearts of people across the earth. Devoted to worship and ministry;
Love, Resonate is comprised of musicians, ministers, and worship leaders.
Based in Southern California, they are blessed to share the love of Christ
manifested in art, music, and ministry.
(E) PRESENTER: Nina Baumgardner
Jesus is risen… Got joy? Do you know what joy even is? Come hear about what joy is, where
you can find it, and why your life needs it.
Nina is the Coordinator of Youth Ministry at St. Therese of Carmel in our very own Diocese of
San Diego!
PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER
PARTICIPANT’S NAME: ___________________________________________________________________________________
BIRTH DATE: ___________________________________________________ SEX: _______________
PARENT/GUARDIAN’S NAME: _____________________________________________________________________________
HOME ADDRESS: _________________________________________________________________________________________
HOME PHONE: (
) _____________________________ MOBILE PHONE: (
) ________________________________
I, ___________________________________, (parent/guardian) grant permission to ____________________________________,
(name of youth) to participate in this parish youth ministry event that requires transportation to a location away from the parish site. This
activity will take place under the guidance and direction of parish employees from _________________________ (name of parish). A
brief description of the activity follows:
Name of event or activity: ____________________________________________________________________________________
Destination of event or activity: _______________________________________________________________________________
Name of individual in charge: ________________________________________________________________________________
Estimated time of departure and return: ________________________________________________________________________
Mode of transportation to and from event: ______________________________________________________________________
As parent and/or legal guardian, I remain legally responsible for any personal actions taken by ______________________ (name of
youth). I __________________________, (parent/guardian) agree on behalf of myself, my child’s other parent if known or living, or our
heirs, successors, and assignees, to hold harmless and defend________________________ (name of parish), the Diocese of San Diego; its
officers, directors, agents, volunteers, chaperones, and representatives associated with the event with respect to any and all actions, claims
or demands that may be made or brought against the parish, the Diocese of San Diego; its officers, directors, agents, volunteers,
chaperones, and representatives associated with the event, arising from or in connection with my child attending this event or in
connection with any illness, injury or cost of medical treatment in connection therewith. I agree to compensate the parish, the Diocese of
San Diego; its officers, directors, agents, volunteers, chaperones, and representatives associated with this event for reasonable attorney’s
fees and expenses arising in connection therewith.
Signature___________________________________________________Date__________________________
MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for
his/her health.
*Of the following statements pertaining to medical matters, sign only those in accordance with your wishes*
EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I hereby grant permission to transport my child to a
hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment administered by the hospital or
doctor.
In the event of an emergency, if you are unable to reach me at the above numbers, please contact:
NAME & RELATIONSHIP: ___________________________________________________________________________________
PHONE: (
) __________________________________________________________________ (HOME/MOBILE)
FAMILY DOCTOR: ________________________________________ PHONE: (
) ___________________________
FAMILY HEALTH PLAN CARRIER: ___________________________________________________________________________
POLICY NUMBER: _________________________________________________________________________________________
Signature______________________________________
Date_______________________
OTHER MEDICAL TREATMENT: In the event it comes to the attention of the parish, the Diocese of San Diego; its officers,
directors, agents, volunteers, chaperones, and representatives associated with the activity that my child becomes ill with symptoms such as
headache, vomiting, sore throat, fever or diarrhea, I want to be contacted.
Signature ______________________________________
Date_______________________
MEDICATIONS: My child is taking medication at present. My child will bring all medications necessary, and such medications will
be well labeled. Names of medications and concise instructions for seeing that the child takes such medications, including dosage and
frequency of dosage is as follows:
___________________________________________________________________________________________________________
Signature_______________________________________
Date_______________________
MEDICATIONS: CHOOSE ONE OF THE BELOW LISTINGS: (A OR B)
A) No medication of any type whether prescription or non-prescription may be administered to my child unless the situation is lifethreatening and emergency treatment is required.
A) Signature_______________________________________ Date_______________________
B) I hereby grant permission for nonprescription medication (such as aspirin, throat lozenges, cough syrup) to be given to my child, if
deemed advisable.
B) Signature_______________________________________ Date_______________________
SPECIFIC MEDICAL INFORMATION
The parish will take reasonable care to see that the following information will be held in confidence.
Allergic reactions (medications, foods, plants, insects, etc.)____________________________________________________________
Immunizations: Date of last tetanus/diphtheria immunization: __________________________________________________________
Does child have a medically prescribed diet? _______________________________________________________________________
Any physical limitations? ______________________________________________________________________________________
Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking,
bedwetting, fainting? _________________________________________________________________________________________
Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, H1N1, etc.? If so, date
and disease or condition: _______________________________________________________________
You should be aware of these special medical conditions of my child: ________________________________________________
___________________________________________________________________________________________________________
PHOTO/VIDEO RELEASE
I,_________________________________________ (parent/guardian) authorize the Office for Youth Ministry (OYM) of the Catholic
Diocese of San Diego, its representatives, or volunteers, to photograph or record on audio or video (tape or digital)
__________________________________________ (name of youth) for purposes of furthering the mission of the OYM, in this specific
case, the creation of publication materials for adults who participate in ________________________________(event & date). Photos,
audio, or video may be used in printed materials and any other visual display or media. I understand that such photos and/or video
recordings will be used for OYM related purposes and will not be used for any commercial purpose whatsoever. I therefore hereby waive
any kind and all rights I may have for remuneration of any kind that could otherwise accrue for the uses of such photos and/or audio or
video recordings.
Signature_______________________________________
Date_______________________
CONSENTIMIENTO DEL PADRE/TUTOR
EXENCIÓN DE RESPONSABILIDAD E INFORMACION MÉDICA
NOMBRE DEL PARTICIPANTE:_____________________________________________________________________________
FECHA DE NACIMIENTO: ___________________________________________________ SEXO: ________________________
NOMBRE DEL PADRE(S) O TUTOR:__________________________________________________________________________
DOMICILIO: ______________________________________________________________________________________________
TELEFONO (CASA): (
) __________________________TELEFONO (MOBIL): (
) _______________________________
Yo, ___________________________________, (padre/tutor) otorgo permiso a ____________________________________, (nombre
del participante) a que forme parte de este evento parroquial/diocesano del ministerio juvenil. Entiendo que se requiere el transporte a un
lugar fuera del sitio parroquial. Este evento se llevara acabo bajo la orientación y dirección de los empleados de la parroquia de
_________________________ (nombre de la parroquia). Una breve descripción de el evento sigue:
Nombre del Evento: ____________________________________________________________________________________
Lugar del Evento: _______________________________________________________________________________
Nombre del individuo a cargo: ________________________________________________________________________________
Tiempo de partida y retorno: ________________________________________________________________________
Medio de Transporte: ______________________________________________________________________
Como padre y/o tutor legal, permanezco legalmente responsable por cualquier acción personal tomada por ______________________
(nombre del participante). Yo, __________________________, (padre/tutor) estoy de acuerdo en nombre de mi hijo(a), esposo(a),
sucesores, herederos, y cesionarios de mantener indemne de toda responsabilidad y defender a ________________________ (nombre de
la parroquia), la Diócesis de San Diego; sus funcionarios, directores, agentes, voluntarios, acompañantes, y representantes asociados con el
evento; con respecto a cualquier y todas las acciones, reclamaciones o demandas que puedan introducirse, o ya en contra de la parroquia, la
Diócesis de San Diego, sus oficiales, directores, agentes, voluntarios, acompañantes y representantes asociados con el evento, que surja de o
en conexión con mi niño que asiste a este evento o en conexión con cualquier enfermedad, lesión o costo del tratamiento médico al
respecto. Estoy de acuerdo en compensar a la parroquia, la Diócesis de San Diego, sus oficiales, directores, agentes, voluntarios,
acompañantes y representantes asociados a este evento, los honorarios razonables de abogados y gastos generados en relación con la
misma.
Firma_____________________________________________
Fecha__________________________
ASUNTOS MEDICOS: Afirmo que mi hijo(a) está en buena salud, y asumo toda responsabilidad sobre la misma.
* Favor de contestar el siguiente cuestionario medico, solo firme aquello que este de acuerdo a sus deseos *
TRATAMIENTO MEDICO DE EMERGENCIA: En el caso de una emergencia, yo doy permiso para transportar a mi hijo(a) a un
hospital para tratamiento de emergencia médica o quirúrgica. Deseo ser informado antes de cualquier tratamiento adicional administrado
por el hospital o el médico. En el caso de una emergencia, si no pueden comunicarse conmigo, favor de llamar:
NOMBRE & RELACION: ___________________________________________________________________________________
TELEFONO: (
) __________________________________________________________________ (CASA/MOBIL)
MÉDICO FAMILIAR: ________________________________________
PHONE: (
) ___________________________
NOMBRE DE ASEGURANZA/PLAN DE SALUD: ________________________________________________________________
NUMERO DE POLIZA: ______________________________________________________________________________________
Firma____________________________________________
Fecha____________________________
OTRO TRATAMIENTO MEDICO: En el caso que algún empleado parroquial, la Diócesis de San Diego, sus oficiales, directores,
agentes, voluntarios, acompañantes y representantes asociados con el evento, vea necesaria la administración de medicamento a mi hijo(a)
por presentar síntomas tales como dolor de cabeza, vómitos, dolor de garganta, fiebre o diarrea, deseo que me notifiquen inmediatamente
antes de administrar cualquier medicamento.
Firma _________________________________________
Fecha_____________________________
MEDICAMENTOS: Mi hijo (a) actualmente esta bajo el siguiente tratamiento. Mi hijo (a) se hará cargo de llevar todos sus
medicamentos y de tenerlos bien etiquetados. Los nombres de los medicamentos e instrucciones concisas para la administración, dosis y
frecuencia es la siguiente:
___________________________________________________________________________________________________________
Firma_______________________________________
Fecha_______________________
MEDICAMENTOS: FAVOR DE ESCOJER UNA DE LAS OPCIONES: (A O B)
A) Ningún tipo de medicamento deberá ser administrado al menos que se encuentre la vida de mi hijo (a) en peligro de muerte y sea
necesaria atención medica.
A) Firma____________________________________
Fecha_______________________
B) Yo otorgo permiso para que se le administre medicamento sin receta a mi hijo (a) como (aspirinas, pastillas para la garganta, jarabe para
la tos) si la situación lo amerita.
B) Firma____________________________________
Fecha_______________________
DATOS IMPORTANTES MEDICOS
La parroquia se tomara el cuidado especial de ver que la siguiente información se mantenga confidencial.
Reacciones Alérgicas (medicamentos, comidas, plantas, insectos,etc . ) _________________________________________________
Vacunas: Fecha de la vacuna ante el tétano/difteria: __________________________________________________________
¿Lleva su hijo (a) una dieta especial? _______________________________________________________________________
¿Alguna limitación física? _____________________________________________________________________________________
¿Su hijo (a) padece de nostalgia crónica, reacciones emocionales a las nuevas situaciones, el sonambulismo, orinarse en la cama o
desmayos?_________________________________________________________________________________________
¿Su hijo (a) ha estado expuesto a alguna enfermedad contagiosa o condiciones, como las paperas, el sarampión, la varicela, el H1N1, etc?
En caso afirmativo, anote la fecha y la condición o enfermedad:
_________________________________________________________________________________________________________
También deben de estar conscientes de las siguientes condiciones médicas especiales de mi hijo (a): __________________________
___________________________________________________________________________________________________________
FOTO/VIDEO PRENSA
Yo ,_________________________________________ (padre /tutor) autorizo a la Oficina de Jóvenes de la Diócesis Católica de San
Diego, sus representantes, o voluntarios, para fotografiar o grabar en cinta de audio o vídeo (digital) a
__________________________________________ (nombre del participante) con fines de promover la misión del Ministerio de
Jóvenes, en este caso específico, la creación de materiales de publicación para los que participan en
________________________________( evento y fecha). Fotos, audio o video puede ser utilizados en materiales impresos y pantallas de
visualización o de otros medios de comunicación. Entiendo que este tipo de fotos y / o grabaciones de vídeo se utilizará para fines
relacionados con el Ministerio de Jóvenes y no serán utilizados con fines comerciales de ningún tipo. Por lo tanto, la presente renuncio a
cualquier tipo y todos los derechos que pueda tener una remuneración de cualquier clase que de otro modo se podrían derivar para los usos
de estos tipos de fotos y/o grabaciones de audio o video.
Firma______________________________________
Fecha _____________________________________