2018 ADULT- Registration - Michaela Farm Day Service Trip

DATE: Saturday, September 22

REGISTRATION DEADLINE:
Wednesday, September 19

The farm is operated by the Sisters of Saint Francis and relies on the help of volunteers
to keep its program running. We will be given various jobs to do, and we’ll also
have a tour of the farm. This will count as 8 hours of service.

All adults must have completed Safe & Sacred and have a current background check on file.

WHERE:
Michaela Farm
3127 State Rd. 229
Batesville, IN 47006

TIME:
We will meet in the St. Susanna Parking lot at 7:00 a.m. We will aim to be back from the farm around 4:00 p.m.

COST: $5

Adult Chaperone Name Adult Chaperone Name First Last
Cell Phone # Cell Phone # - ### - ### ####
Email
Home Phone Home Phone - ### - ### ####
Emergency Contact Name Emergency Contact Name First Last
Emergency Contact Relationship
Emergency Contact Phone # Emergency Contact Phone # - ### - ### ####
Family Doctor
Doctor Phone # Doctor Phone # - ### - ### ####
Health Plan Carrier
Policy Number
LIABILITY WAIVER
In consideration of the opportunity 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, I am in good health, and I assume all responsibility for my health.

I understand that I may be photographed, unidentified in group situations; and I hereby grant permission to be photographed for releases to the Criterion and/or Archdiocesan website, Parish bulletin boards, and/or other Parish promotions.
I, the undersigned, have read this release and understand all its terms and execute it voluntarily and with full knowledge of the significance.

Please 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.
I agree to abide by the expectations for adult leaders. I have an completed Archdiocesan Background Check and the online Safe & Sacred training to serve as a Chaperone.

Draw your signature into the box below:

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Full Name

I understand this is a legal representation of my signature.