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Missionpalooza Registration!
Please fill out one form per youth who will be attending Missionpalooza, August 6-10, 2018.
Participant Name *
Your answer
Address (include City & Zip) *
Your answer
Grade for 2018-2019 School Year *
Your answer
Participant Email *
Your answer
Parent Email *
Your answer
Participant Cell Phone
Your answer
Parent Cell Phone *
Your answer
Secondary Contact Name & Phone *
Your answer
Congregation *
Your answer
Planning to attend Seabreeze trip on August 10? *
Required
T-Shirt Size *
Required
Medical Information
Please be as thorough as possible. If not applicable please write "N/A" or "No"
Is there any medical condition we need to be aware of? *
Your answer
Any allergies to food, medicine, etc? *
Your answer
Any physical conditions that may limit participation in any activities? *
Your answer
Any special dietary needs or restrictions? Suggestions for substitutions? *
Your answer
Is the participant under a doctor's care for an existing condition? Please describe. *
Your answer
Any prescribed medical treatment or medicine to be taken during the hours of Missionpalooza? Please provide instructions (dosage, frequency, with food or drink, etc) *
Your answer
Other health concerns for leadership to be aware of? Please describe. *
Your answer
Physician's Name & Phone Number *
Your answer
Insurance Carrier *
Your answer
Insurance Policy/ID number *
Your answer
I give my permission for my child to attend Missionpalooza. In case of emergency, I understand that every effort will be made to contact me. In the event I cannot be reached, I hereby authorize any necessary emergency medical care, and agree to pay all charges connected with such treatment, not covered by insurance. (Type electronic signature) *
Your answer
I further give permission for my child to ride in any vehicle driven by an approved adult chaperone while attending and participating in Missionpalooza. My youth and I understand that seat belts shall be worn at all times during transportation. (Type electronic signature) *
Your answer
My child may be photographed and recorded and those images and sound may be used for promotional materials/media for the diocese. *
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