2018 ADULT- Registration 6th-8th ZipCity Trip

DATE: Saturday, November 3
REGISTRATION DEADLINE:
Thursday, November 1

TIME:
1:30-5:00 p.m.
Please arrive no later than 1:30 p.m.
*We will be meeting in the parking lot of Saint Susanna. Let me know if you can help drive and how many total fit in your car.
**Parents will pick up their children AT ZipCity at 5:00 p.m.

COST: $30 ONLY IF YOU WANT TO PARTICIPATE IN ACTIVITIES - DUE Thursday, November 1
Please register online and turn in a check (written to St. Susanna)
*contact Ellice Bedel if you would like to pay $33 by credit card =)
*we will be carpooling to Zip City
*Parents will pick up individually at Zip City

STUDENTS & Adults who want to participate MUST WEAR TENNIS SHOES TO PARTICIPATE IN ALL ACTIVITIES
--COST INCLUDED 3 Hours of Unlimited Activities:
Laser Tag, Trampolines, Rock Wall, Zip Line, and Ropes Courses

*Bring extra cash if you want to play arcade games or get snacks
*One bottled water will be provided (and you can refill it at the water fountains)--no outside food is allowed, so I cannot provide snacks.

Adult Chaperone Name Adult Chaperone Name First Last
Cell Phone # Cell Phone # - ### - ### ####
Email
Willing to drive?

Willing to drive? I am willing to drive I am not willing to drive
If you are willing to drive list the total number of passengers in your vehicle. If you're not driving put NA
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:

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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

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