Christ the Redeemer Youth Ministry

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Welcome to Adult Registration for chaperones and core team for the Confirmation I Retreat with Christ the Redeemer Youth Ministry. This retreat would not be possible without your help! We look forward to serving the needs of the community and our students with you.

We will cover your expenses as our way of saying Thank you! We couldn’t do this without you!

Remember that the email you register with is the one we will send information to.

Your Information

First Name: *

Last Name: *

Gender: *

Home Address: *

City: *

Zip Code: *

Best Phone To Reach You: *

(xxx)xxx-xxxx

E-mail: *

A confirmation will be e-mailed to this address.

Job: *

Would you like to be with your child? *

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.

Media Release: *

Medical Information

The following request is pertinent information if you are rendered unconscious.

Date of Birth (mm/dd/yyyy): *

(including year)

Date of Last Tetanus shot: *

Please list ALL medical conditions/allergies/special health information including bouts with depression and anxiety.

Medical Conditions/Allergies/
Special Health Info:

Please list ANY medications (prescription or non-prescription) you would like us to be aware of.

Medications:

Insurance Information

Do you have Medical Insurance: *

Insurance Carrier:

Name of Insured

Insurance Policy Number:

Emergency Contact: *

Phone Number: *

(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.