Welcome to Adult Registration for Mid-America 2019! This would not be possible without your help. We are looking forward to serving with you during this conference. At this time a non-refundable deposit of $50 is due.

Qty
Description
Amount
Total
1

$50.00
$50.00
Total: $50.00
Future Commitment: $0.00
Your Information
(xxx)xxx-xxxx
A confirmation will be e-mailed to this address.
CONSENT TO PARTICIPATE AND LIABILITY RELEASE:
I hold harmless and discharge the Archdiocese of Galveston-Houston, Christ the Redeemer Catholic Parish, its staff and volunteers from any and all liability, claim, loss, damage, cost or expense arising from my participation in this event listed above. I waive such claims against such organization or any such person, arising directly or indirectly from or attribute in any legal way, to any action or omission to act of any such organization or person in connection with execution of this event. I authorize treatment by a licensed medical physician or licensed medical team in case of any accident or illness that may so arise, or any hospitalization necessary.
I have read this release statement, and I understand and voluntarily agree to its provisions.
Audio/Visual Recording and Photography Consent:
On occasion, video recordings, audio recordings, photographic slides, and photographs are taken of children, youth, and adults during church and diocesan sponsored activities. These are utilized in newsletters, websites, event promotion, advertisements and other printed media. I release the staff and volunteers of Christ the Redeemer Catholic Parish and the Roman Catholic Archdiocese of Galveston-Houston from any liability connected with the use of my picture or audio/video recording as part of any of the above or similar activities.
The following request is pertinent information if you are rendered unconscious.
Medical Information
(xxx)xxx-xxxx
(please include area code)
(including year)
Please list ALL medical conditions/allergies/special health information including bouts with depression and anxiety.
Please list ANY medications (prescription or non-prescription) you would like us to be aware of.
Insurance Information:
(xxx) xxx-xxxx
Medical Release
In the event that you do not have insurance, payment in full for medical care becomes the responsibility of the patient. I authorize treatment by a licensed medical physician or licensed medical team in case of any accident or illness that may so arise, or any hospitalization necessary.
I have read this consent for Medical Release, and I understand and voluntarily agree to its provisions
In clicking the box I agree to abide by any/all policies and rules established for this event/activity. Should I not be able to maintain the guidelines and expectations of the adult chaperones/young adult assistants, I understand that there will be consequences for my actions, which could include being asked to leave the event.
Your Payment Information

VisaMasterCardDiscoverJCB

Powered by Acceptiva