PARTICIPANT DETAILS *
Please note that registration is only open to teens from participating parishes and organizations entering into Junior or Senior year of High School. Not sure if your parish or organization is participating just contact us.
Student Information
Student Name *
Student Name
Date of Birth *
Date of Birth
Grade for your 2018-2019 Academic Year *
Student Home Address *
Student Home Address
Contact Phone
Contact Phone
Parish Information
Please indicate the name of your Youth Leader or the person who recommended you to the Institute.
Medical Information
Name of Parent or Legal Guardian *
Name of Parent or Legal Guardian
Emergency Contact Phone #1 *
Emergency Contact Phone #1
Emergency Contact Phone #2
Emergency Contact Phone #2
What are other medical conditions that we should be aware of?
Medical Release *
I request that the above named participant be allowed to attend the University of Mary Summer Institute on June 21st-23rd, 2018. In consideration of being allowed to participate in this event or activity, I RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE the University of Mary, Board of Trustees and their officers, agents, or employees (“the University”), as well as the Diocese of Phoenix and Newman Center from any and all liability, claims, demands, or cause of action arising out of or related to any loss, damage, or injury, including death, that may be sustained by me (or my child), or to any property belonging to me (or my child) while participating in this event or activity, or while on the premises of the University. I have actual knowledge and appreciation of the particulars of the event or activity and associated dangers and risks and voluntarily assume those risks, including property damage, personal injury or death that may be sustained, or consent to assumption of risks for my child. I agree to review and abide by applicable safety policies and rules for the event or activity. I am (or my child is) in good physical condition and I am not aware of any physical infirmity which would place me or my child at risk to participate in the event or activity. During the period of the event or activity, I grant permission for University staff or Parish Youth Minister obtain medical treatment on my behalf for my student if I or the emergency contact cannot be reached. Prescription medication will be given in its original container with dosage information on it. I understand that reasonable precautions will be taken to safeguard the health and well-being of my student and that I will be contacted immediately in case of emergency or accident. I acknowledge I will be responsible for any and all costs of medical coverage and treatment provided not covered by insurance and I grant permission for emergency medical treatment in the event I cannot be reached. This Liability Release and Waiver shall be construed according to Arizona law. To the maximum extent permitted by law, I voluntarily release and indemnify the University from and against any present or future claim, loss or liability for injury to person or property which I (or my child) may suffer, or for which I may be liable to any other person, during my participation in the event or activity.
Code of Conduct
We expect the best of our students. We hold students to a high standard of behavior.
Behavior Agreement *
My student, named above, will dress and act respectively; use no verbal or physical abuse of self or others; will not have in their possession at any time: drugs, alcohol, or tobacco of any kind; will be responsible for their own belongings; will not leave the designated area at any time for any reason without contacting the adult in charge, and will review these guidelines with me, their parent/legal guardian, prior to signing below. I understand that if my student is involved in any illegal activity or serious destructive behavior that I will be contacted immediately and be responsible for their immediate transportation home. (For students staying overnight. I also acknowledge that my student will be staying in the San Pablo dormitory of Arizona State University.
Dorms *
To get the most out of the UMary Summer Institute we encourage students to stay in our overnight accommodations at ASU San Pablo Hall. Please let us know if your are staying overnight by selecting an option below.

A HARD COPY OF THE PERMISSION SLIP WILL BE EMAILED TO YOU FOR PARENT/GUARDIAN SIGNATURE. PAYMENT OF $35 IS DUE TO THE UNIVERSITY OF MARY. PLEASE TURN INTO YOUR YOUTH MINISTER OR CHAPERONE WITH CHECK OR CASH,