Jenkins mission trip

December 17th-19th in Jenkins, Kentucky

Cost: $100 (payable to St. Catharine)

Deadline to Register: December 11th

 

Adult Chaperone Registration and Release

Please complete the form below

I. Registration
Name *
Name
Address *
Address
Cell Phone *
Cell Phone
Date of Birth *
Date of Birth
II. SPECIFIC MEDICAL INFORMATION AND MEDICATION
A. Specific Medical Information. The Parish will take reasonable care to see that the following information will be held in confidence.
EMERGENCY MEDICAL CONTACT AND TREATMENt
In the event of an emergency, the undersigned hereby give(s) permission to be transported to a hospital.
Emergency Contact Name *
Emergency Contact Name
Phone *
Phone
Phone *
Phone
Phone *
Phone
III. RELEASE AND INDEMNIFICATION
A. Release. The undersigned on behalf of the undersigned, the Participant, and the heirs, successors and assigns of the undersigned and the Participant, hereby release, hold harmless from any liability, and discharge from all direct or derivative claims, actions, causes of actions, medical expenses, costs, legal expenses, other expenses and all other damages at law or in equity, known or unknown, direct or indirect, choate or inchoate against the Diocese of Columbus, the Parish and all current and former employees, agents, clergy, officers and volunteers of the Diocese of the Parish, arising from the Participant’s participation in the Activity named in Section I.B., above. B. Indemnification. The undersigned shall indemnify and hold harmless the Diocese of Columbus, the Parish, and all current and former employees, agents, clergy, officers and volunteers of the Diocese of Columbus or the Parish from any claim, liability, suit, judgment, loss, damage, expense, fee or cost (including court costs and attorney fees) arising directly or indirectly from the Participant’s participation in the Activity named in Section I.B., above, unless arising from the negligence of an indemnified party.
IV. CODE OF BEHAVIOR
The Participant shall comply with the following:
Adults. Adults shall at all times conduct themselves in a lawful manner appropriate to the Activity. Adults shall act with respect for all other participants in the Activity. Adults shall act in accordance with the principles of the Roman Catholic Church. Student Activities. Adult participants shall at all times be present and shall chaperone students assigned by group leader. Adult participants will supervise and monitor the movement of students throughout the activity. Adult participants will insure that no .students enter areas specifically prohibited. Adult participants will insure that no students enter any rooms or areas that are not appropriately chaperoned by two adults. Adult participants will use safe environment practices such as not meeting with students in secluded areas; making sure enough adults are chaperoning all activities; observing other adults who are interacting with youth; and notifying OYYAM staff of any inappropriate activities throughout the duration of the activity. Adult participants will respect that the sessions are designed for the benefit of students and will refrain from excessive questions or participation in the sessions. The possession or use of alcohol, tobacco, drugs, or weapons of any kind by students or adult participants is not permitted. Failure to abide by this Code of Behavior may result in a request for the adult to leave the premises.
V. SAFE ENVIRONMENT COMPLIANCE
Check here if this information is on file at the parish
Date of Criminal Background Investigation
Date of Criminal Background Investigation
Protecting God's Children
Protecting God's Children
*
Digital Signature *
Digital Signature
Date *
Date

If you are paying by cash or check, simply hit submit and you are finished! (payment due by Dec. 11th)

If you want to pay online via St. Catharine's secure online giving site, hit submit and follow the directions given.