ST. SUSANNA- 2017 PARTICIPANT- Registration - 6th-12th Kings Island Day

DATE: Wednesday, July 12, 2017

TIME:
Please arrive no later than 7:00a.m.
*We will be meeting in the parking lot of Saint Susanna:
1210 E. Main St.
Plainfield, IN 46168
**Parents should plan to pick-up at approx. midnight

COST: $40
Please register online and turn in a check (written to St. Susanna)
*we will be riding the St. Susanna bus

*6th-7th Graders will be in groups with adult chaperones during the day. 8th-12th graders will check in during the day, but will be with chaperones all day.

OTHER DETAILS:
*Please bring money to purchase lunch and dinner (you can bring a lunch if you're carrying a bag in the park
*You are welcome to wear a swim suit under clothes, but two pieces must be covered up by a tank top or t-shirt.
*Make sure you also bring or wear sunscreen!

Student Name Student Name First Last
#1 Parent Name #1 Parent Name First Last
#1 Parent Cell Phone #1 Parent Cell Phone - ### - ### ####
#2 Parent Name #2 Parent Name First Last
#2 Parent Cell Phone #2 Parent Cell Phone - ### - ### ####
Parent Email
Participant Cell Phone #- Put NA if they will not have a phone with them
Grade for 2017-2018 School Year
Gender
School Disctrict
Emergency Contact Name
Emergency Contact Relation
Emergency Contact Phone # Emergency Contact Phone # - ### - ### ####
Allergies, Medical Condition, Dietary Needs, or any other Special Needs:
**Put 'NA' if it is Non-Applicable
Medication: If medications (prescription and non-prescription) are needed, please send them with your child. List these medications in the following section and include product name and physician's instructions on dosage and frequency. Any medicine brought on the ski trip should be clearly labeled in their original container and given to the Coordinator of Youth Ministry upon arrival to St. Susanna.
**Put 'NA' if this is Non-Applicable
Family Doctor
Doctor Phone # Doctor Phone # - ### - ### ####
Health Plan Carrier
Policy Number
LIABILITY WAIVER
Please sign below to indicate you have read and agree to the terms of the following Liability Waiver:

I grant my son/daughter permission to participate in the 2017 Kings Island Trip on Wednesday, July 12, 2017.

In consideration of the opportunity for my child to participate and fully recognizing that such an undertaking involves an element of risk, we assume all risks and hazards incidental in such participation and do hereby release, absolve, indemnify, and agree to hold harmless St. Susanna Parish, the Archdiocese of Indianapolis, its agents, employees and offices and the chaperones, leaders, organizers and sponsors, and persons. Neither the Archdiocese of Indianapolis/St. Susanna Parish nor any of said persons shall be held financially responsible for any injury, illness, or death incurred as a direct or indirect result of the activity. 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.

In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical treatment to be administered. I wish to be advised prior to any further treatment by the hospital or doctor.
We, the undersigned, have read this release and understand all its terms and execute it voluntarily and with full knowledge of the significance.
(Parent, draw your signature into the box below)

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.