Jan 15, 2018- PARTICIPANT- Registration - 6th-8th Grade Plainfield SKYZONE

DATE: Monday, January 15
(DATE CHANGED!!! TAKE NOTE)
STEP #1- Complete this Online REGISTRATION form by:
Monday, January 15

STEP #2
Fill out the online waiver form for skyzone: It’s a new waiver so EVERYONE needs to do this please
https://plainfieldstore.skyzone.com/waiver/

TIME:
Please arrive at 6pm
*We will be meeting at SkyZone in Plainfield Address:
851 Columbia Rd STE 172
Plainfield, IN 46168
**Parents should plan to pick-up at 8:00 p.m.

COST: Bring $13 with you Jan. 15 - CASH or Check written to St. Susanna ($11 if you bring your own skysocks)

Student Name Student Name First Last
Student Cell Phone # Student Cell Phone # - ### - ### ####
Parent Email
Home Phone Home Phone - ### - ### ####
#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 - ### - ### ####
Grade
Gender
School
Emergency Contact Name (other than parents)

Emergency Contact Name (other than parents)

First Last
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
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 Wiaver:

I grant my son/daughter permission to participate in the St. Susanna SkyZone Event on Monday, January 15, 2018.

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.