Youth Group Escape Room 2020
Sunday January 26, 2020
6:00-9:00pm
Cost: $15 per person (checks made payable to St. James)

Space is limited, so register now!

Parents should drop off and pick up at St. James.

We will need parent chaperones/drivers to transport youth to Team Escape 262. If you are willing, please indicate at the bottom of this registration and include how many youth you can fit in your car. Thank you!

Please complete this registration by Tuesday January 21st

Indemnity Agreement:
**In consideration for my child/ward participation, I agree to reimburse and indemnify parishes for all reasonable legal and court fees incurred by parishes in defending a lawsuit that I or my child/ward may bring against parishes, which relates to the above named activity if is found not legally liable by the courts and prevails in the lawsuit. If the parishes are found legally liable for injuries sustained by son/daughter/ward, this paragraph will not apply. I certify that I have an understanding of this agreement and any risks and hazards associated with the activity described above that my child/ward will be participating in. I further understand that I have the opportunity to fully discuss this agreement with a representative of the parishes to clarify any concerns or questions about the activity or this agreement that I may have. As parent or guardian of the above named student, I give permission for my child to participate in the field trip described above.
**Photo & Video Release: I hereby give my permission to the parishes for photographs and/or videos that may include my child’s image to be used in promotional materials. This includes any prints, slides, copies, reductions, or any other processes or treatments necessary to make a photograph/video for reproduction purposes. I release all rights and privileges for financial obligations for this permission.
**In the event of an emergency, I give permission to transport my child to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by the hospital or doctor.
Email address *
FIRST NAME OF SON/DAUGHTER *
Your answer
LAST NAME OF SON/DAUGHTER *
Your answer
PARENT/GUARDIAN FULL NAME *
Your answer
HOME ADDRESS *
Your answer
ALTERNATE EMAIL ADDRESS
Your answer
BEST PHONE TO CONTACT DURING EVENT *
Your answer
ALTERNATE PHONE *
Your answer
ALTERNATIVE CONTACT (If unable to reach you) *
Your answer
ALTERNATIVE CONTACT BEST PHONE DURING EVENT *
Your answer
PHYSICIAN'S FULL NAME *
Your answer
PHYSICIAN'S PHONE *
Your answer
NAME OF MEDICAL INSURANCE *
Your answer
MEDICAL INSURANCE POLICY NUMBER *
Your answer
PERTINENT MEDICAL CONDITIONS
Your answer
INHALER/EPI-PEN
ANY FOOD ALLERGIES TO BE AWARE OF? *
Your answer
Are you able to chaperone and drive youth from St. James to Team Escape 262?
If yes, how many youth can you drive in your vehicle?
Your answer
By entering my full name, I attest that this constitutes my legal electronic signature on this form. *
Your answer
A copy of your responses will be emailed to the address you provided.
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