Eucharistic Youth Rally “Fired Up”

Registration Slip: Adult     Eucharistic Youth Rally                            Date: Sat. Nov. 3 & 4, 2007

The undersigned hereby releases, forever discharges, and agrees to hold harmless The Diocese of Buffalo, St. Mary of the Angels Parish, Archbishop Walsh High School, and its respective members, directors, employees, and agents against any and all liability, claims, demands, lawsuits and expenses of any kind whatsoever which may be incurred or suffered by the me including attorney fees and expenses and costs sustained by the afore mentioned as a result of negligent, willful or intentional acts by me while attending the Eucharistic Youth Rally at Archbishop Walsh High School.  

I hereby give permission to St. Mary’s Parish and its respective staff and adult volunteers to take me, to a doctor or hospital and hereby authorize medical treatment, including but not limited to emergency surgery and I fully and completely assume all responsibility for all medical bills.  Further, should it be necessary for me to return home due to medical reasons, disciplinary action or otherwise, I assume all responsibility and transportation costs. 

In signing this I am granting my permission to be transported in privately owned vehicles to and from the event.  As well I am aware of the rules and responsibilities that I am expected to uphold and respect.  I also understand and agree that my likeness and/or name may be used in a future promotion of Saint Mary of the Angels.

Information:  

Name:                                                                                         Age:            

Address:                                                                                                        _ 
                                                                               CITY            STATE          ZIP
Phone Number:                                               Cell:                                 __ 

Date of Birth:                                        Insurance Carrier:                                 

Medication & Reason for:                                                                                   

Physician’s Name & Phone Number:                                                          

Relevant Medical History:                                                                       

Dietary Needs & Reason for:                                                                               

Emergency Contact (Relation) & Phone:                                           ________________

Diocesan Virtus Training: Protecting God’s Children:

Diocese of Buffalo Virtus Training: Date Completed:___________ Place: _______________________  

Video/Photography Release:

I ______________________________________________ understand that my photograph and/or likeness and name may be used in a future promotion of the Rally by St. Mary of the Angels. 

Signature:                                                     ___________________Date:                            

Chaperones: Free                                                               Youth: Chaperone Ratio -  7:1

Mail forms all forms: Debbie McPherson, Youth Rally, 601 West Henley St., Olean, NY 14760

                ------------------------------------------RALLY USEONLY--------------------------------------         
Make sure registration table has table has the following for this participant

_____Permission Slip    ____Sleeping Room Assignment             

Check Number_____________________                        Receipt Number_______________________