Participant's Name:_______________________________________________________________________
Parent's
Name:___________________________________________________________________________
Address:________________________________________________________________________________
City:__________________________________ Zip:________________
Phone:________________________
Date of Birth: ______/______/______
Age: __________ Male: __________ Female:_____________
School Attended: _____________________________________
Grade Level: _________________________________________
ADULT HELP IS ALWAYS NEEDED WITH THIS PROGRAM. WILL YOU BE WILLING TO HELP
AS NEEDED TO DRIVE, BAKE, CHAPERONE, OR FACILITATE? YES
__________ NO__________
NIGHT OF THE WEEK THAT WORKS BEST FOR YOU
(Circle One)
WEDNESDAY SUNDAY
RELEASE OF LIABILITY
As parent or legal guardian, you remain fully responsible for any legal responsibility
which may result from personal actions taken by your child. We, the
parents or legal guardians of ____________________________,
do hereby
release from liability, St. Gerald Church and any adult sponsors and
church staff in the event of any accident en route, during and returning
from a Horizons event. We understand that it may be necessary for
our son/daughter to help transport other youth or ride with other
youth. I have indicated if I desire otherwise.
__________________ I request that my child ride only with an adult
driver.
__________________ I request that my child does not drive other youth
to a Horizons event.
MEDICAL MATTERS: I hereby warrant that to the
best of my knowledge, my child is in good health, and I assume all
responsibility for the health of my child. My child has the
following special needs:____________
_________________________________________________________________________________________
In the event of an emergency, I hereby
give my permission to transport my child to a hospital and/or emergency
room for medical treatment.
Insurance Information:
_________________________________________________________________________
Date:_____________
Signature: ________________________________________
If you are unable to reach me at the above number, please call: _________________________________
Photos may be taken of participants for use in Youth Ministry related
publications such as our newsletter, Spirit Link, and our Web site.
Names will be withheld on our Web Site.
REGISTRATION FEE: $10.00/Child - Family Maximum/$20.00, Out of
Parish $20.00/Child.
Scholarships are always available.
