Mission Possible Service Week
June 7-11, 2015
Summer In-Town Mission Experience for Middle School &
High School Students!
Incoming 6th-12th grade students (2015-2016 school year) are invited to join “Mission Possible” 2015 Service Week with participants
from all around the Dallas Diocese. Mission Possible is an inter-parish, Diocesan supported, in-town service week. 2015 marks the
21st year for this event!!! This summer our parish will be a part of the Central Region and joining youth from St. Joseph & St. Paul
Catholic Church. Are you willing to brave the heat…get off the couch…and SERVE?!?!
Mission Possible service week:
Monday thru Thursday of that week, participants will gather at our host parish, St. Joseph Catholic Church in the Dining
Hall each morning at 8:30am. We will start off each day with our own Mission Possible prayer experiences. After our
morning prayer time, youth will gather in work crews to participate in crew team building activities & prepare for their
day of service. Crews will travel to different non-profit organizations each day in an effort to expose participants to a
variety of service opportunities.
Each participant brings their own lunch and the crews take time at their service site to eat, process their day
and pray together. Time will be spent each day directed toward “service learning” activities based on our
Catholic Social Teachings.
The cost for youth participants is $55 which covers daily snacks, T-shirt,
work supplies for the week, transportation cost to sites, and entrance
to Hawaiian Falls on Thursday during our closing day fun activity.
Registration form & payment due by Wednesday, May 13th!
Mission Possible Schedule Overview:
Sunday, June 7th
3:00pm – 6:00pm
Gather at St. Patrick (9643 Ferndale Rd.; Dallas TX 75238) for MP Opening Family Session & Youth
Mass to be held at 5 p.m.)
Mon – Wed, June 8th -10th
8:30am – 4:00pm
Gather & Pick up your child from St. Joseph Catholic Church Dining Hall
th
Thursday, June 11
8:30am – 6:00pm
Gather at St. Joseph as usual / Parents pick up child from Hawaiian Falls Water Park (Garland)
Each participant brings their own lunch and the crews take time at their service site to eat, process their day and pray together.
Time will be spent each day directed toward “service learning” activities based on our Catholic Social Teachings.
This week is only possible with the help of caring Adult Leaders!!!
Space availability for youth participation is based on the number of Safe Environment “cleared” adult leaders
who are willing to commit to the week.
If you are interested in volunteering as an adult leader
Please contact Kimberly Garza at [email protected] or (972)235-2598
Baby sitting for younger children of adult leaders is provided at NO charge
ADULT LEADER TRAINING— There will be an adult leader training at St. Joseph on Wednesday, May 27 from 6:30pm-8pm in the St.
Joseph Youth Center. This training can count toward your annual Safe Environment Program renewal training!
JUST SO YOU KNOW...Here’s what ALL Participants of MP must agree to!
CODE OF CONDUCT for “Mission Possible” Service Week participants:
1. I agree to treat other participants, leaders, staff, clients and residents with respect and understand that all adult leaders have the authority to discipline me.
2. I will always follow the schedule and guidelines given to me.
3. I understand that alcohol, weapons (including ALL knives), fireworks, tobacco products of any kind, illegal drugs
and profane or abusive language are NOT ALLOWED on any part of this activity. (Prescription drugs for minors
must be dispensed by adult leader except inhaler.)
4. I understand that I represent St. Paul Catholic Church and agree to behave in a Christian and positive manner at all
times. I further agree to dress appropriately during this activity. (Shorts should be at least fingertip length).
5. Sexual indiscretion (includes inappropriate touching) is prohibited at all times and in all cases.
6. No participant is allowed to leave before activity conclusion, without written parent permission
7. In the event of an emergency or other need to contact any participants, the staff must know where I can be located,
therefore I agree to stay with my assigned group at all times.
8. I agree to arrive no earlier than 10 minutes prior to scheduled start time of event and be picked up no later than 10
minutes after scheduled event conclusion. By attending this function all participants agree to stay until the function’s conclusion, unless they have a medical emergency. I realize that I, and my parents, will be financially responsible for any damage I do to others’ property, facilities or vehicles.
9. I understand that if I choose to violate any part of this “code of conduct”, I run the risk of having my parents notified by phone, or in person, and asked to pick me up, immediately. (This determination will be left to the discretion of the event coordinator.)
10. I understand MP is a “service” activity. I WILL be called to WORK as part of a crew!
11. MP NAMETAGS must be worn and visible AT ALL TIMES. This holds your name tag and medical release form.
“Basic” required duties of an Adult Leader:
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Be willing to facilitate a small work crew; by overseeing the crew during service learning, work site, team building
and large group activities. (Facilitation training and instruction will be provided)
Must be 21 years or older and have completed “Safe Environment” process and training in their home parish.
Complete “Volunteer Driver” form and provide copy of current driver’s license and vehicle insurance card to Parish
Youth Ministry coordinator
Have a vehicle in good working conditions with properly functioning seatbelts, brakes, tires and wiper blades.
Agree to participate in all Mission Possible Service week activities, unless other arrangements have been made with
Parish MP Coordinator.
Attend MP Adult Leader training to be held on Wednesday, May 27 at 6:30pm in the St. Joseph Youth Center
Pray for all participants of Mission Possible…especially their work crew!!
Additional “Code of Conduct” items for Adult Leaders:
 I understand my primary function during Mission Possible is to ensure the safety and wellbeing of all youth participants in a safe and faith-filled environment – especially, but not limited to, those in your group.
 I will know the whereabouts of all youth in my charge at all times…including breaks.
 I will be assertive, while compassionate, in guiding the young people with whom I work.
Please Note: Since space availability for participants is based on
the number of “Cleared” Adults committed to the week,
registrants will be notified, by the Youth Ministry office, if they are on the “participant list”
or have been put on the “wait list”
***Participants and volunteers will be emailed additional specific information
once they have registered for the event.**
MISSION POSSIBLE SERVICE WEEK June 7-11, 2015
Cost: $55 (make checks payable to “St. Paul”) - Deadline May 13th
Please return form & payment to the Youth Ministry Office located in the Parish Center.
YOUTH
REGISTRATION
After your Registration form is received, you will be contacted—via email—as to whether you are on the “Participant List” or the
“Wait List” (We are limited as to the number of youth participants, based on the number of “cleared adults” we have committed
to the week.) For more information, contact Kimberly Garza at [email protected].
PLEASE PRINT—YOUTH INFO: CIRCLE T-Shirt Size Youth L or Adult sizes: S M L XL 2XL
We would like to donate additional funds for scholarships and supplies...here is our donation of $ _____________
3XL
4XL
Last name________________________ First name_____________________ D.O.B___/___/__ Gender: M or F
Hm. Address___________________________________ City_________________
State____
Zip______________
For office use
date________
Youth E-Mail_____________________________________ Parent E-Mail__________________________________
ck.# ________
Church ________________________________ Grade (2015-2016 school year) ________
cash________
One friend I would like to be grouped with - __________________________________ (no guarantees, but we’ll try)
PARENT, GUARDIAN or CONSERVATOR—INITIAL any that apply — **DO NOT INITIAL ALL AREAS AS ONE MAY CANCEL OUT ANOTHER**
______ This child takes no medication and will bring no medication with him/her.
______ This child takes medication/s and will self-medicate. The child will bring all such medications necessary, and such medications will be clearly labeled. I understand that the child will be required to turn all medication(s) over to a supervising adult designated to keep medication(s). I further understand
that it will be this child’s responsibility to present himself/herself at a location designated for returning medication(s) to this child at the frequencies/times
listed below. I understand that the adult to whom this child surrenders the medication has no medical training and this adult will not measure dosages. This
child will return the medication(s) to the adult after he/she self-medicates. At the conclusion of the event it will be this child’s responsibility to pick up
remaining medication(s), if any, at the self-medication designated location. Names of medications and exact dosage and frequencies/times are as listed
below: ___________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
NOTE: Should your child have an Emergency Injection Device (Epi-Pen), Diabetic Condition, Asthmatics with a rescue inhaler, or other special medical condition, it is
important to provide a clear description as to the nature of the medical condition and any medication. This is important for situations where the youth becomes unable to selfadminister these treatments and to communicate with Emergency Response Personnel. If a child, who is normally able to self-administer these medications becomes unable to
self-administer or is in distress, youth ministers, volunteers, or other parish personnel will immediately call 911 to summon Emergency Medical Personnel to respond to the
medical emergency. Youth ministers, volunteers, and other parish personnel are NOT trained to administer these types of emergency medications.
______This child takes medication but is unable to self-medicate. Child’s parent/guardian/conservator will provide all medications, for an adult to dispense.
______I grant permission for the following nonprescription medication to be given to this child:
Non-aspirin/pain reliever Yes ________ No ________ # of tablets per dosage________
Decongestant Yes ________ No ________ # of tablets per dosage________
Antihistamine Yes ________ No ________ # of tablets per dosage________
Throat Lozenge Yes ________ No ________
Antacid Yes ________ No ________
Other ___________ Dosage ______________
Specific Medical Information:
Allergic reactions (medications, foods, plants, insects, etc.) _____________________________________________________
Immunizations: (date of last tetanus/diphtheria immunization) _______________________________
Other Medications child currently takes: _________________________________________
Any physical limitations: ______________________________________________________
Has child recently been exposed to contagious disease or condition such as mumps, measles, chicken pox, etc.? Y N
If so, date and disease or condition. _______________________________________________________________________
Any other special medical conditions of this youth that we should be aware of?
______No medication of any type, prescription or nonprescription, may be given to this child, unless emergency treatment is required in life-threatening
case.
PLEASE COMPLETE BOTH SIDES OF FORM
PLEASE PRINT
YOUTH participant Last Name_____________________________, First Name_____________________
TO BE FILLED OUT BY PARENT, GUARDIAN, CONSERVATOR
CONSENT TO PARTICIPATE AND LIABILITY RELEASE
I, _________________________________________ the parent/guardian/conservator of ________________________ (child name)
grant permission for my son/daughter to participate in all youth activities and functions.
I understand that as parent/guardian/conservator, I remain legally responsible for any personal actions taken by my son/daughter. I recognize the
inherent risk associated with the various youth activities that my son/daughter will be participating in. I agree on behalf of myself, my son/daughter
named herein, my heirs, successors, and assigns to indemnify, defend, and hold harmless St. Joseph Catholic Church, St. Patrick Catholic
Church, St. Paul Catholic Church, the Roman Catholic Diocese of Dallas, their employees and/or volunteers from any and all claims (unless due
to the Sole or Gross NEGLIGENCE of the Parish) for illness, injury, death, and the cost of medical treatment therewith, arising from or in any way
connected with my son/daughter participating and/or attending the various youth programs and activities during this formation year noted above.
In the event any legal action is taken by either party against the other party to enforce any of the terms and conditions of this release, it is agreed
that the unsuccessful party to such action shall pay to the prevailing party therein all reasonable court costs, reasonable attorneys’ fees and
expenses incurred by the prevailing party.
AUDIO/VISUAL RECORDING AND PHOTOGRAPHY CONSENT
On occasion, video recordings, audio recordings, photographic slides, and photographs are taken of children and youth during church and
diocesan sponsored activities. These are utilized in newsletters, websites, event promotion, advertisements and other printed media. As the State
of Texas does not prevent audio or video recording or the photographing of children/youth (with the exception of Senate Bill 1, Section 26.009,
which deals specifically with school districts), it does encourage parental consent. Additionally, current video recordings and photographs assist
law enforcement agencies dealing with the Missing Children’s Program.
I ___ consent / ___ do not consent (check one) to the use of such materials in which my child may appear. I release the staff and volunteers of
St. Joseph Catholic Church, St. Patrick Catholic Church, St. Paul Catholic Church and the Roman Catholic Diocese of Dallas from any liability
connected with the use of my child’s picture or audio/video recording as part of any of the above or similar activities.
AUTHORIZATION OF CONSENT TO TREAT MINOR
I, _____________________________ am the (initial one) ___ parent ___ guardian or ___ conservator of ___________________________
(child name), a minor, and as such do hereby authorize St. Joseph Catholic Church, St. Patrick Catholic Church, St. Paul Catholic Church, its
youth ministry leaders, employees, contractors and volunteers as agent(s) for the undersigned to consent to any x-ray examination, anesthetic,
medical, dental, or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or
specific supervision of any physician or surgeon licensed under the laws of the jurisdiction where such diagnosis or treatment may be given,
whether such diagnosis or treatment is rendered at the office of said physician, at a hospital, or at any other location. It is understood that this
authorization is given in advance of any specific treatment or diagnosis, but is given to provide authority and power of treatment, or hospital care
which the aforementioned physician in the exercise of best judgment may deem advisable. This authorization is given pursuant to the provisions
of Chapter 32 of the Texas Family Code. This authorization shall remain effective throughout the specific event dates listed above. In consideration of acceptance of this authorization, but without any time limitation and without any future right of revocation, I hereby release, defend and hold
harmless the Parish and Roman Catholic Diocese of Dallas (Diocese), their officers, directors, agents, employees, volunteers, youth ministry leaders, and contractors from all claims, liabilities and loss in any way arising out of or in connection with or relating to such treatment and treatment
decisions.
Insurance Carrier: ___________________________________________________________________________________
Policy Number: ___________________________________ Insurance ID Number: _____________________________
**PLEASE ATTACH A PHOTOCOPY, front and back, OF Child’s HEALTH INSURANCE CARD**
_________________________________________________________
Signature of Parent/Guardian/Conservator
_______________________________
Date Signed
PRINTED Name of—Parent, Guardian, Conservator __________________________________
Home Phone Number_____________________________
Mobile Phone Number____________________________
Address (if different than the child’s) ______________________________________________
Parent, Guardian, Conservator E-Mail_______________________________________________________
__________________________________________________________ _______________________________
PRINTED—Name & Relationship of Secondary Emergency Contact
Mobile Phone Number
My child and I have read and agree to the “Code of Conduct” (available on the Mission Possible Informational page)
Adults...St. Paul Youth Ministry needs
your Help to make our
“Mission Possible”
Adult Leaders are needed to help facilitate
“Mission Possible” Service Week June 7-11, 2015
Sunday, June 7
Mon-Wed
Thursday, June 11
2:45-6:15pm
8:30am—4:00pm
8:30am—6pm
Mission Possible is an Inter-Parish, in-town service activity for Middle School,
High School Youth and “Cleared” Adult Leaders which began in 1995! This event is
supported by the Diocese of Dallas and usually has participation from over 1,200 participants, from 28 parishes.
Youth Participation in Mission Possible is limited to a ratio of 5 Youth per 1 “Cleared” Adult Leader. Therefore, it is VERY
important for us to begin the process of lining up our Adult
leadership for this amazing event NOW! Please consider sharing your time with youth!
Adult Leader TRAINING is provided and babysitting “MP kid camp” is free & available by
reservation for the younger children of Adults who commit as Adult Leaders for the week!
A $50 gas reimbursement is also given to adult crew leaders.
Prior to the event, Adult Leaders need to...
 Be 21years old or older and complete the Diocese of Dallas “Safe Environment” Process by May 27.
 Attend the Adult Leader Mission Possible training session scheduled for Wednesday, May 27.
from 6:30-8pm in the Youth Center at St. Joseph
During “Mission Possible Service Week” Adult Leaders are asked to...
 Attend the kick off activities at St. Patrick on Sunday, June 7th (3:30-6:30pm)
 Help facilitate small group (Crew) activities and discussions
 Provide transportation for their crew to and from service sites
 Connect with service site coordinator and other crews at the service site
 Help oversee Crew during activities while at service site
 Help transport youth for our closing FUN activity at Hawaiian Falls in Garland
For more information—please contact Kimberly Garza
[email protected] or (972) 235-2598
To VOLUNTEER as an Adult MP Leader — please Complete the
“Adult Mission Possible REGISTRATION” form
and return it the St. Paul Youth Ministry office before May 13!
MISSION POSSIBLE SERVICE WEEK
June 7-11, 2015
There is NO CHARGE for “Cleared adults”
who volunteer for MISSION POSSIBLE
Babysitting is available, by reservation,
for younger children of Adult MP Volunteers.
Please Register by May 13th...so that we may better judge how many YOUTH we will be able to place on the
“Participant List.” Remember, Mission Possible is a 5 day event.
M.P. Adult Leader Training will be at St. Joseph on Wednesday, May 27 at 6:30pm in the Youth Center
PLEASE PRINT - ADULT REGISTRATION
Please circle T-shirt size: S M L XL 2XL
3XL 4XL
Last Name_____________________________ First Name___________________ D.O.B.______/______/______ Gender: M or F
Address_____________________________________________ Hm Phone#__________________ Cell #_______________________
City___________________________________ St_________ Zip____________ Church____________________________________
Email___________________________________________ NUMBER #____ of seatbelts in my vehicle—INCLUDING the driver.
CHECK ONE: ____ I would like my MS or HS aged child in my crew - My child’s name is ______________________________
____ I would not - like my child in my crew
CONSENT/RELEASE FORM
I hereby agree to participate in “Mission Possible Service Week June 7-11, 2015 with St. Joseph Catholic Church AND the “Central Region” as
previously listed. I understand all reasonable precautions will be taken to keep adult and youth participants safe during this event. I will not hold St.
Joseph-Richardson, St. Patrick-Dallas, St. Paul-Richardson, the Diocese of Dallas, members of their staff or their volunteers, responsible for accidental
harm or injury that may occur during this activity. In case of an emergency during this time, I hereby consent to and authorize the giving of treatment
and or medication ordered by a physician or adult for my care.
On occasion, video recordings, audio recordings, photographic slides, and photographs are taken of participants of church and diocesan sponsored
activities. These are utilized in newsletters, websites, event promotion, advertisements and other printed media. I consent to the use of such materials
in which I may appear. I release the staff and volunteers of the above named entities from any liability connected with the use of my picture or audio/
video recording as part of any of the above or similar activities.
I have read and agree to the “Code of Conduct” (available on the Mission Possible Informational page)
Adult Participant Signature_____________________________________
Date__________________
Ins. Co. Name & Phone__________________________________________________________________ Policy#____________________
Current Medications: _____________________________________________________________________
Allergies_________________________________________________________________________________
Emergency Contact Name and Number_______________________________________________________
Special health considerations:____________________________________________________________________________________
I DO need babysitting: Name and age(s) of child(ren)
___________________________________________ Age_____
___________________________________________ Age_____
___________________________________________ Age_____