"Dog Days of Summer" Trip to Mount Olympus 2019
Tuesday, August 13th, 2019 from 8:00am - 9:00pm

Drop off and pick up at Good Shepherd (N88W17658 Christman Road, Menomonee Falls, WI 53051)

Mode of Transportation: Bus or Chaperone Vehicles

Cost: $45 (includes lunch and dinner) PLEASE MAKE CHECKS PAYABLE TO "GOOD SHEPHERD"

Friends ALWAYS welcome!

Deadline for sign-up: August 6th, 2019

Email address *
Participant Information
Participant 1 First Name *
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Participant 1 Last Name *
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Participant 1 Gender *
Participant 1 Grade (Fall 2019) *
Participant 2 First Name
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Participant 2 Last Name
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Participant 2 Gender
Participant 2 Grade (Fall 2019)
Participant 3 First Name
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Participant 3 Last Name
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Participant 3 Gender
Participant 3 Grade (Fall 2019)
Parish or Friend Of *
Parent Information
Parent/ Guardian First Name *
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Parent/ Guardian Last Name *
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Alternate Email
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Contact Information During Event
NAME OF CONTACT PERSON *
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BEST PHONE FOR CONTACT PERSON *
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ALTERNATIVE CONTACT NAME (If unable to reach person above) *
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ALTERNATIVE CONTACT BEST PHONE *
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Medical Information
PHYSICIAN'S FULL NAME *
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PHYSICIAN'S PHONE *
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NAME OF MEDICAL INSURANCE *
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MEDICAL INSURANCE POLICY NUMBER *
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PERTINENT MEDICAL CONDITIONS
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INHALER/EPI-PEN
Allergy Information
ANY FOOD ALLERGIES TO BE AWARE OF?
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Would you like to help out?
Would you like to chaperone? We need adults willing to chaperone. Please indicate the number of youth you can fit in your vehicle (if needed) in "Other"
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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.
By entering my full name, I attest that this constitutes my legal electronic signature on this form. *
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