Catholic Diocese of Austin Texas

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STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Adult Registration Form

Catholic Scout Day 2017 will be held on August 5, 2017 at Sacred Heart Catholic Church in La Grange (539 E Pearl St, La Grange, TX 78945). The day will begin at 8 a.m. and conclude with 5 p.m. Mass. Lunch will be provided.

All participants must submit a registration form with payment.

Check One

Religious Emblem Counselor Training

$20.00

Receive Diocese-mandated training to lead an Ad Altare Dei, Pope Pius XII, Marian Medal, or Spirit Alive religious emblem group. Training is concurrent to youth program. Fee includes materials and meals.

Volunteer

$10.00

Help with room preparation, food prep, clean up; if Ethics & Integrity trained, may assist with youth. Please register no later than 2 weeks in advance if volunteering.

Marian Medal Volunteer

$25.00

Chaperone

$10.00

Drive Scouts to and from Scout Day, assuming you are staying on the premises and eating lunch/snacks with us. Fee pays for your lunch and snacks.

Total: $0.00

Your Information:

First Name: *

Last Name: *

Mailing Address: *

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Home Phone: *

“xxx-xxx-xxxx”

Cell Phone:

Birthdate:

E-mail: *

A receipt will be e-mailed to this address.

Marital Status:

Occupation:

Employer:

Languages Spoken:

Parish: *

Scouting Position:

BSA Council:

District:

Unit:

Chartered Organization:

GSUSA Council:

Troop/Unit:

Other Youth Organization (Camp Fire, AHG, etc.):

Comments/Questions:

Adult Consent and Release for Medical Treatment:

For Adult Participants, Age 21 and Older

In Case of Emergency: *

In the event that I am not coherent or conscious, I hereby grant adult chaperones of the Diocesan Catholic Committee on Scouting permission to act on my behalf in seeking emergency medical treatment for myself in the event that such treatment is deemed necessary.

Medical Treatment: *

I hereby give my permission to those administering medical treatment to do so.

Liability Waver: *

I further absolve and release Sacred Heart Catholic Church, its employees and volunteers, as well as the Diocese of Austin and its employees and volunteers, from any liability whatsoever when acting on my behalf in regard to medical treatment and in any other respect deemed necessary should I become incapacitated.

Media Release: *

Additionally, I give my permission to be photographed during activities associated with the above-mentioned event. I understand that said photos/videos may be used for future publicity with the parish, Diocese, and/or Catholic Church.

Agreement of Terms: *

I acknowledge that submitting this form signifies that I am in agreement with all the statements on this form. Furthermore, I agree to abide by all policies and expectations regarding adult leaders/chaperones as put forth by the Diocesan Catholic Committee on Scouting and the Catholic Diocese of Austin. My primary function on this trip is to ensure the safety and well-being of all participants in my charge. I will refrain from any actions/behaviors that are not consistent with the teachings of the Catholic Church and any that could be potentially harmful to myself and any other participants.

Name of Participant:

Address:

City/State/Zip:

Phone:

Social Security Number:

Insurance Company:

Policy Number:

Insurance Address/Phone:

Place of Employment Providing Insurance:

Please email a photocopy of the Insurance Card to austinDCCSchair@gmail.com.

Additional Information:

Additional information regarding medical history, allergies, medications, or other conditions

In the event of an emergency:

Emergency Contact: *

Relationship:

Emergency Contact Phone: *