REGISTRATION FORM FOR SPECIAL ACTIVITIES AND FIELD TRIPS

DIOCESE OF BURLINGTON

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Parish or Sponsoring Group: Burlington Life Teen, Reflective Lenten Friday

Activity: Teen Led Stations of the Cross, Stone Soup Meal, vewing of the Passion of the Christ & Discussion

Destination:  St. Joseph Co- Cathedral Drop of 6:45pm-Pick up 11:15 pm

Supervising Adult:   Name & # Monica Morano 233-9647

Mode of Transportation:    N/A

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Teen’s Name:  __________________________________________Age/Grade: _____________

Parent(s)/Guardian:  ________________________________________Phone:  ________________

Address:  __________________________________City/State/Zip:  ________________________

Emergency Contact:  _______________________________________ Phone: ________________

Health Insurance Company:  ________________________________________________________

Health Insurance Policy Number:  ___________________________________________________

Any Special Medical Needs that We Should Be Aware of: ________________________________

Is the participant currently under a doctor, psychologist or psychiatrists care? _________________

If so, please explain:  ______________________________________________________________

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Parent/Guardian—Please read carefully:

I request that my son/daughter participate in the above-described activity and consent to their viewing of the Passion of the Christ which I understand is an R rated movie.

Should emergency medical treatment be necessary and I am unable to be contacted immediately, I authorize the delegated agents of the above-mentioned organization to act on my behalf and approve appropriate treatment.

I specifically waive claim or claims that may be derived from any accident or injury sustained by my son/daughter en route, during, and returning from the activity.  I further agree to indemnify and save harmless the above name parish/school, the Diocese of Burlington, their staff and all adult supervisors working on their behalf.

Parent/Guardian Signature:  ___________________________________________Date:  _____________________________________

Participant Expectations: I have read the Participant Expectations for this event as set forth on the information sheet and understand what is fully expected of me.  I agree to follow these expectations at all times during the event

Signature of Teen Participant  Date