Register Only - Clone of DRAFT

Summer BLAST 2026

Believers Learning And Serving Together
St. Mary of the Lake of the Lake Catholic Church

Justin Kelly, Coordinator of Youth Ministry, Gr. 6-8

Email: jkelly@stmarys-wbl.org

Office: 651-429-7771 option 1

Tuesdays, June 23 and 30, July 9, from 8:45 AM-5:00 PM.
Meet at the Parish Life Center.

Youth will do acts of service each morning (some one-site, some off-site).
Afterwards, youth will go to an off-site activity for fellowship and fun.
We will return to the Parish Life Center at 5:00 PM.

Cost: $50 per day or $130 for all three days
First Name*
Last Name*
Birthdate*

MonthDayYear
Date
Gender

MaleFemale
Current Grade*
Which days will you attend? ($50 per day or $130 for all three)

All Three DatesJune 23June 30July 7
Participant T-shirt Size (generic adult size)*
Participant's Cell Number

Area CodePhone Number
Primary Parent/Guardian Name

First NameLast Name
Primary Parent/Guardian Email *
example@example.com -- This email will be added to subscription list for email communications.
Primary Parent/Guardian Phone Number*

Area CodePhone Number
Primary Parent/Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2 Name

First NameLast Name
Parent/Guardian #2 Phone Number

Area CodePhone Number
Parent/Guardian #2 Email
example@example.com -- This email will be added to subscription list for email communications.
Parent/Guardian #2 Address (If different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Adult Volunteers

Must be 21+
Volunteer Name

First NameLast Name
Volunteer Email
example@example.com
Volunteer Phone Number

Area CodePhone Number
All volunteers are required to complete the "Essential 3" (online training, background check and sign Code of Conduct). Have you done the E3?

I have already completed the E3I am not sure if I did the E3I have not done the E3
What day(s) can you help? (Choose all that apply)

June 23June 30July 7
Justin will follow up with all volunteers to help complete or update their Essential 3 and discuss expectations and needs.

I (your name)* grant permission for my child(child's name)* to participate in this parish event that requires transportation to a location away from the parish site. This event will take place under the guidance and direction of parish employees and/or volunteers from St. Mary of the Lake Catholic Church.
A brief description of the activity follows:

Type of Event: Summer BLAST - Service projects and activities, both on and off site

Dates of Event: Tuesdays, June 23 & 30, and July 7, from 8:5 AM (meet at St. Mary's Parish Life Center) until 5:00 PM (return to Parish Life Center)

Cost: $50 per day or $130 for all 3 days

Destination of Event: Varies each day. (Example destinations, White Bear Lake Food Shelf, Bunker Beach Water Park.) A calendar will be provided.

Individual(s) in charge: Justin Kelly; office: (651) 429-7771, option 1| cell: (651) 492-8252 | e-mail: jkelly@stmarys-wbl.org, and St. Mary's chaperones

Estimated Time of Departure: Meet at St. Mary's Parish Life Center (school) at 8:45 AM

Estimated Time of Return: Approximately 5:00 PM

Mode of Transportation To & From Event: Bus
I understand and agree that as parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“student/participant”). Further, I hereby warrant that to the best of my knowledge, my child is in good health and I assume all responsibility for the health of my child.

I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St. Mary of the Lake, its officers, directors, employees and agents, and the Archdiocese of Saint Paul and Minneapolis, its employees and agents, chaperones, or representatives associated with the event and activities (hereinafter “Releasees”), from any claim, including but not limited to all claims relating to communicable disease, arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate Releasees for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of Releasees and is not related to communicable disease (see communicable disease release, hold harmless and indemnification agreement below).

Communicable Disease Release, Hold Harmless & Indemnification Agreement: I agree to hold Releasees harmless, release, defend, and indemnify Releasees for any communicable disease claim arising out of the above Event that is brought against Releasees by myself, participant, my family members, heirs, assigns, executors, and personal representatives. I understand and agree this communicable disease release, hold harmless, and indemnification agreement includes claims based on the actions, omissions, or negligence of participant, myself, and others, including, but not limited to the Releasees.
By typing my signature below, I acknowledge and agree this electronic or digital signature is the legally binding equivalent to my handwritten signature. This electronic or digital signature has the same validity and meaning as my handwritten signature. By typing my signature below as guardian, I acknowledge and agree to the conditions above. Electronic Signature*

Clear
Please type your full name*

First NameLast Name
Date*

MonthDayYear
Date

EMERGENCY CONTACT AND EMERGENCY MEDICAL INFORMATION:

The parish will take reasonable care to see that the following information will be held in confidence.

In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. In the event of an emergency, if you are unable to reach me at the above numbers, contact:
Emergency Contact Name*

First NameLast Name
Relationship*
Cell Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Email*
example@example.com
Child's Allergies or Medical Conditions*
Child's Medications*
Family Doctor/Physician's Name*
Phone Number*

Area CodePhone Number
Family Health Plan Carrier*
Policy/Identification/Group Number*
Hospital/Clinic Preference*
By checking this box I am acknowledging that I have read the above statements and agree to all of the above stated considerations and conditions. *

Click here to check box.
By typing my signature below, I acknowledge and agree this electronic or digital signature is the legally binding equivalent to my handwritten signature. This electronic or digital signature has the same validity and meaning as my handwritten signature. By typing my signature below as guardian, I acknowledge and agree to the conditions above. Electronic Signature*

Clear
Please type your full name*

First NameLast Name
Date*

MonthDayYear
Date

AUTHORIZATION, CONSENT AND RELEASE FOR USE OF VISUAL LIKENESSES AND ORIGINAL WORKS OF MINORS

This form allows you, the parent or guardian, to identify if images of your child and their original works may be used for purposes of print, online, social media communication and promotion.
I am the parent or legal guardian of * ("My Child").
I grant the following rights to St. Mary of the Lake Catholic Church and the Archdiocese of Saint Paul and Minneapolis:

1.     The right to use all photographs, pictures, portraits, vocal sounds, appearances/likenesses, video and performances (hereinafter collectively known as “image”) of My Child in the possession of St. Mary of the Lake Catholic Church;

2.     The right to use, reproduce, publish, exhibit, distribute, and transmit the image of My Child individually or in conjunction with other images or printed matter in the production of brochures, slides, motion pictures, broadcasts (radio, television, and other social and digital media), audio or video files, recordings, still photography, CD-Rom and any other manner of media now known or later developed;

3.     The right to use, reproduce, publish, exhibit, distribute, and transmit the image of My Child individually or in conjunction with other images or printed matter St. Maryy of the Lake Catholic Church and the Archdiocese of Saint Paul and Minneapolis’s Internet websites. No home address or phone number will be published;

4.     The right to record, reproduce, amplify, edit, and simulate My Child’s image and all sound effects produced;

5.     The right to copyright, in the name of St. Mary of the Lake Catholic Church and the Archdiocese of Saint Paul and Minneapolis, works that contain the image of My Child;

6.     The right to use and publish for general communications, advertising, commercial or publicity purposes, or for any other lawful purpose whatsoever My Child’s original work; and

7.     The right to assign the above-mentioned rights to third parties without notice to me.

I understand that the video files, still photos, or other media incorporating the image of My Child will become the property of St. Mary of the Lake Catholic Church. I hereby waive the right to inspect or approve the image or any finished materials that incorporate the image.

I understand and agree that no compensation will be provided, now or in the future, in connection with the use of My Child’s image or My Child’s original work.

I hereby release, discharge, and agree to indemnify and hold harmless St. Mary of the Lake Catholic Church , the Archdiocese of Saint Paul and Minneapolis, and their agents, employees and assigns from any and all claims, demands, right, and causes of action of whatever kind that I or My Child have or may have or may arise by reason of this authorization and from the use of My Child’s image and original work, including but not limited to, all claims for libel and invasion of privacy.

This consent regarding My Child’s likeness and original work is valid until such time as I choose to rescind this authorization and consent. If I choose to rescind this authorization and consent, I agree that I will inform St. Mary of the Lake Catholic Church in writing and that my rescission will not take effect until it is received by St. Mary of the Lake Catholic Church. I understand and acknowledge that it may not be possible to recall any work or photos that have been published prior to receipt of my written rescission.
I hereby authorize and consent that St. Mary of the Lake Catholic Church and the Archdiocese of Saint Paul and Minneapolis have the right to use My Child’s name in connection with their educational, promotional, fund-raising activities, or for any other legitimate purpose. By selecting an option and typing my initials below, I acknowledge and agree this electronic or digital signature is the legally binding equivalent to my handwritten signature. This electronic or digital signature has the same validity and meaning as my handwritten signature. By typing my signature below as guardian, I acknowledge and agree to the conditions above.*

YesNo
Please Initial*

Clear
Signature of Parent/Guardian: By signing my signature below, I acknowledge and agree this electronic or digital signature is the legally binding equivalent to my handwritten signature. This electronic or digital signature has the same validity and meaning as my handwritten signature. By typing my signature below as guardian, I acknowledge and agree to the conditions above.Electronic Signature*

Clear
Parent First & Last Name*

First NameLast Name
Date*

MonthDayYear
Date

Please verify that you are human*
Should be Empty:

Summer BLAST 2026

Adult Volunteers

AUTHORIZATION, CONSENT AND RELEASE FOR USE OF VISUAL LIKENESSES AND ORIGINAL WORKS OF MINORS