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Into the Dark - 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 'Into the Dark' retreat to be held on June 19th, 2021 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.
  
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  T-shirt Size REQUIRED Please fill out this field.
  
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  (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:
  
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  In the event that participant does not have insurance, payment in full for medical care becomes the responsibility of the patient.
  
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  In signing the line above 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.
  
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- Contact Us
  
  Clint Carton
  
  Associate Director of Youth Ministry
  
  281-332-3031 ext. 127
  clint.cartonsaintmcc.org

St. Mary Catholic Church

League City, TX
Archdiocese of Galveston-Houston

Into the Dark - Adult

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