Beruflich Dokumente
Kultur Dokumente
June 21,2014
St. Joseph Parish
Registration Form
CFC Region:______________________________
Name:___________________,
_________________
Last Name
Shirt Size: XL
___________________________
First Name
Street Address
_______
M.I.
Address:_____________________________________
_____________
Nickname
______________________
City
Zip Code
Phone/Cell phone:______/________/__________
Email:_________________________________________
Birthday:______/______/_________
Age:_______
Gender:
Male Female
Medical
Medications:____________________________________________________________________________
Physical Limitations/Food Allergies:_______________________________________________________
Medical Condition:_______________________ Health Insurance Carrier:__________________________
Policy Number: __________________________ Cardholders Name:_______________________________
Primary Care Doctor:_____________________ Doctors Phone:___________________________________
I, the undersigned ( participant | parent of youth | guardian of youth) hereby acknowledge that on
June 21, 2014, the participant, whose name appears above, is scheduled to take a trip to St Joseph
Catholic Church in St. Louis, MO for the event arranged by the Couples for Christ-Youth. In the event of an
emergency, I hereby give permission to transport the participant to a hospital for emergency medical,
dental, anesthetic or surgical treatment. I agree to pay for any expenses incurred for such treatment. I
hereby release, indemnify, and hold harmless the Couples for Christ or any parish thereof, its employees,
ministries, agents, representatives, affiliates, and volunteers from any and all demands, claims, injury, and
liability arising out of the participants action in the program. I hereby waive my claim to a lawsuit against
the Couples for Christ, the Diocese of Saint Louis and any such persons for any liability arising out of the
participants action in this activity. I further acknowledge that any injury or loss, regardless of severity, is
required to be reported to the parish.
Signature: _________________________________