FALL RETREAT REGISTRATION - $75November 9-10 2013 ***A MANDITORY $25 LATE FEE will be assessed after that date.
FULL NAME ____________________________________ GRADE _________ T-SHIRT______ CHURCH PARISH _____Saint Joseph Catholic Church______YOUTH MINISTER ___________Jamie Orillion___________ STREET ADDRESS ________________________________________ CITY __________________________ STATE _______ ZIP__________PHONE ( ) _______________________ E-MAIL ____________________________________________________BIRTHDAY ________________________________ SCHOOL __________________________________ GENDER _________ LIABILITY
I hereby consent to participation by the Participant listed above, in the event described above, under the guidance and supervision of the Youth Minister listed above. I understand that the event will take place away from the Church grounds and that my child will be under the supervision of the designated chaperons on the said dates. The undersigned do hereby release forever, discharge, and agree to hold the Diocese of Lafayette, St. Joseph’s Church in Rayne and Woodman of the World (Camp Woodman) or any & PHOT
Hospital or Medical Center used while on the trip harmless from and against any and all liability, claims, demands, lawsuits and expenses arising from personal injury, sickness, death or property damage of any nature whatsoever which may be incurred or suffered by the undersigned and/or the participant while attending activities. Furthermore, the undersigned assumes all risk of personal injury, sickness, death, damage and expense arising from the undersigned’s or participant’s participation in all activities, including recreation and work activities involved in the above activity. We also allow the Church Parish listed above to provide any and all necessary transportation during the event. We also allow the sponsors to use any photographs taken of the participant during the event in all forms, media and manners, without restriction as to changes or alterations, for advertising, trade, promotion, exhibition or any other lawful purposes. Furthermore, the undersigned agree to indemnify and hold the Diocese of Lafayette, St. Joseph and Camp Woodman and/or any Hospital or Medical Center used during the event, and their respective members, direc- tors, employees and agents (collectively, the “Indemnities”), harmless from and against all claims, demands, actions, lawsuits and liabilities, including attorney’s fees and expenses, sustained by the indemnities as the result of the negligent, willful, or intentional acts of the undersigned and/or participant. If the participant is under 18 years of age: We (I), the parent(s) or legal gaurdian(s) of the participant, hereby grant permission for our son/daughter to participate fully in the above activity and all of its undertakings, and hereby give our permission to take said participant to the doctor or hospital and hereby authorize medical treatment, includ- ing, but not limited to, emergency surgery, and we, not withstanding any question of liability involved in this emergency, fully and completely, assume all responsibility for all medical bills. Furthermore, should it be necessary for the participant to return home due to medical reasons, disciplinary action, or otherwise, we (I) assume all responsibility and transportation costs. I hereby grant permission to any staff person to provide the following over-the-counter medicines to my child if requested: ____ Tylenol _____ Benedryl ____ Advil ____ Sudafed ____ Midol ____ Kaopectate ____ Neosporin ____ Pepto Bismol ____ Imodium & EMERGENCY
Name of Family Physician: ____________________________________ Phone #: _________________________ Hospital Information: (Write N/A if no Insurance) Name ________________________________________________ Company _____________________________________________ Address ______________________________________________ Policy Number _________________________________________ Day Phone ____________________________________________ Group Number _________________________________________ Evening Phone_________________________________________ Phone Number _________________________________________ Cell Phone ____________________________________________ Name of Insured ________________________________________ ____________________________________________ ____________________________________________________ Parent/Legal Guardian (please print) Parent/Legal Guardian Signature Date


For discussion

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