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EDGE Spring Retreat - Adult

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  I, (Name), REQUIRED Please fill out this field. Please enter valid data.
  
  do hereby release, hold harmless and discharge the Archdiocese of Galveston-Houston, Saint Mary of the Expectation Catholic Church, its staff and volunteers from any and all liability, claim, loss, damage, cost, or expense arising from my participation in the EDGE Spring Day Retreat to be held on May 3, 2025 at St. Mary of the Expectation Catholic Church in League City, TX. I waive such claims against such organization or any such person, arising directly or indirectly from or attributable in any legal way, to any action or omission to act of any such organization or person in connection with execution of this event. I authorize treatment by a licensed medical physician or licensed medical team in case of any accident or illness that may so arise, or any hospitalization necessary.
  
  Participant
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Gender REQUIRED Please fill out this field.
  
  T-Shirt Size REQUIRED Please fill out this field.
  
  Dietary Restrictions
  
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  Email (Confirmation Receipt) REQUIRED Please fill out this field. Please enter an email address.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Physician's Name Please enter valid data.
  
  Physician's Phone Number Maximum 20 characters Please enter a phone number.
  
  (The following request is pertinent information if you are rendered unconscious)
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Age REQUIRED Please fill out this field. Please enter an integer (number).
  
  Date of Last Tetanus Shot Please enter a date.
  
  Please list ALL medical conditions / allergies / special health information including bouts with depression and anxiety:
  
  Please list ALL medications (prescription or non-prescription) you would like us to be aware of:
  
  Insurance Information
  
  Do you currently have Medical Insurance? REQUIRED Please fill out this field.
  
  Insurance Company Please enter valid data.
  
  Policy in Name of Please enter valid data.
  
  Policy Number Please enter valid data.
  
  In the event that participant does not have insurance, payment in full for medical care becomes the responsibility of the patient.
  
  Name of Emergency Contact REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  In signing below, I agree to abide by any/all policies and rules established for this event/activity. Should I not be able to maintain the guidelines and expectations of the adult chaperones/young adult assistants, I understand that there will be consequences for my actions, which could include being asked to leave the event.
  
  Electronic Signature REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Signature REQUIRED Please fill out this field. Please enter a date.
  
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