2018 ADULT Team - Shanty Town Registration

DATE: Saturday, October 6-Sunday, October 7
Arrive at 1:00 p.m. on Saturday in the church parking lot- We plan to be done on Sunday at 8:45 a.m.

REGISTRATION DEADLINE:
Wednesday, October 4

COST: $15 (helps to cover food costs and service projects for the homeless)
- Please register online and turn in a check (written to St. Susanna) or cash to Ellice Bedel.

Name Name First Last
Parish You Attend
Adult/College Student
Email
Home Phone Home Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Gender
Emergency Contact Name

Emergency Contact Name

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
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:

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.