ADULT TEAM- 2019 Reflections Confirmation Retreat Registration

DATE: Saturday, Nov. 9 - Sunday, Nov. 10**

LOCATION: Bradford Woods- Baxter Village Dining Hall
5040 State Road 67 N.
Martinsville, IN 46151

REGISTRATION DEADLINE:
Wednesday, October 2

COST: $80 for 2 nights, $50 for 1 night -due no later than Thursday, October 24

Please register online and turn in a check (written to St. Susanna) or cash to the Faith Formation Office

**Team Retreat begins on Friday, Nov. 8 at 5:00 p.m.
If you are not able to make the Friday night Leadership retreat you must be at Bradford Woods by 9:00 a.m. on Saturday, Nov. 9.

Name Name First Last
Adult/College Student
Gender
I will helping with the following ministry: (Choose only one option)

I will helping with the following ministry: (Choose only one option) Retreat Team Meal Ministry (Food Preparation/Service)
I will be staying overnight: (choose only one option)

I will be staying overnight: (choose only one option) Friday & Saturday Night Just Saturday Night No Nights (only an option for Meal Ministry team members)
Email
Home Phone Home Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
T-Shirt Size (included with registration cost- if you don't want a shirt deduct $5 from your cost- but please select the option below 'I do NOT want a t-shirt)
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.