2017 ADULT- Registration - 6th-8th Grade Tubing Trip- White River Canoe Co. out of Noblesville, IN

DATE: Saturday, August 19

REGISTRATION DEADLINE:
Wednesday, August 16

TIME:
Please arrive no later than 9:15 a.m.
*We will be meeting in the parking lot of Saint Susanna:
1210 E. Main St.
Plainfield, IN 46168
**We will be back to St. Susanna at approx. 3:00 p.m.

COST: no cost for adults

*Please pack a sack lunch and a change of clothes.
*You are welcome to wear a swim suit under clothes, but two pieces must be covered up by a tank top or t-shirt.
*Make sure you also bring or wear sunscreen!

Adult Chaperone Name Adult Chaperone Name First Last
Cell Phone # Cell Phone # - ### - ### ####
Email
Home Phone Home Phone - ### - ### ####
Emergency Contact Name Emergency Contact Name First Last
Emergency Contact Relationship
Emergency Contact Phone # Emergency Contact Phone # - ### - ### ####
Family Doctor
Doctor Phone # Doctor Phone # - ### - ### ####
Health Plan Carrier
Policy Number
LIABILITY WAIVER
In consideration of the opportunity to participate and fully recognizing that such an undertaking involves an element of risk, we assume all risks and hazards incidental in such participation and do hereby release, absolve, indemnify, and agree to hold harmless St. Susanna Parish, the Archdiocese of Indianapolis, its agents, employees and offices and the chaperones, leaders, organizers and sponsors, and persons. Neither the Archdiocese of Indianapolis/St. Susanna Parish nor any of said persons shall be held financially responsible for any injury, illness, or death incurred as a direct or indirect result of the activity. I hereby warrant that to the best of my knowledge, I am in good health, and I assume all responsibility for my health.

I understand that I may be photographed, unidentified in group situations; and I hereby grant permission to be photographed for releases to the Criterion and/or Archdiocesan website, Parish bulletin boards, and/or other Parish promotions.
I, the undersigned, have read this release and understand all its terms and execute it voluntarily and with full knowledge of the significance.

Please draw your signature into the box below:

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Full Name

I understand this is a legal representation of my signature.
I agree to abide by the expectations for adult leaders. I have an completed Archdiocesan Background Check and the online Safe & Sacred training to serve as a Chaperone.

Draw your signature into the box below:

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