2018 PARTICIPANT- Michaela Farms Service Day 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.

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

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 You Attend
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
PARTICIPATION CONSENT:
I grant permission for my child to participate in the Youth Ministry Michaela Farm Service Trip. I will not hold the Archdiocese of Indianapolis or Saint Susanna Catholic Church responsible in the event of any injury or accident to my son or daughter while participating in this event. I warrant that, to the best of my knowledge, my child is in good health and able to participate in this activity. (Please submit a statement indicating limitations and/or conditions of which we should be aware.)
In case of medical emergency, I understand that every effort will be made to contact parents or guardian of participants. In the event that I cannot be reached, I hereby give permission to the Youth Minister to seek treatment for my son/daughter. I hereby give permission to the medical staff to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child.
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.