SOULstice Registration 2023

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The registration info/liability release required to go on the SOULstice retreat

Email *

Youth's Name (First and Last) *

Youth's Grade (as of Fall 2023) *

Youth's Gender *

Parent/Guardian Name (First + Last) *

Home Address (City, State, Zip) *

Parent/Guardian Cell Number *

Emergency Contact (Other Than A Parent) *

Emergency Contact Relationship to Youth (grandmother, family friend, etc.) *

Emergency Contact Phone Number *

Health Insurance Company *

Policy Number *

Name of Youth's Doctor *

Youth's Doctor's Phone *

Other medical or otherwise pertinent information

I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St. Lawrence, its officers, directors, employees and agents, and the Archdiocese of Mobile, its employees and agents, chaperones, or representatives associated with "SOULstice", from any claim arising from or in connection with my child attending "SOULstice" or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish/school/institution, its officers, directors and agents, and the Archdiocese of Mobile, its employees and agents and chaperones, or representative associated with the event for reasonable attorney’s fees and expenses that may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/school/institution/archdiocese. IN ADDITION, by signing this agreement, I acknowledge the contagious nature of COVID-19 and that my child(ren) and I may be exposed to or infected by COVID-19 by participating in the St. Lawrence activity and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at St. Lawrence may result from the actions, omissions, or negligence of myself and others, including, but not limited to, St. Lawrence employees, volunteers, and program participants and their families. Considering the foregoing, however, I grant permission for my child(ren) to participate in this parish activity taking place off-campus, notwithstanding the risks associated with the COVID-19 virus and group activities. I further agree on behalf of myself, my child named herein, and my spouse, our heirs, successors, and assigns, to release, indemnify, and hold harmless St. Lawrence and The Roman Catholic Church of the Archdiocese of Mobile, their members, directors, officers, employees, agents and representatives (“Indemnitees”) associated with the event arising from or in connection with the negligent acts or omissions of the Indemnitees ONLY in regard to prevention of the spread of the COVID-19 virus. I SPECIFICALLY ACKNOWLEDGE AND AGREE TO THE FOREGOING. *

I agree to sign the above statement electronically

Required

Full Name - ELECTRONIC SIGNATURE *

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms