Edge Nights Registration (2019-2020)
The contact info/liability release required for participation in Edge Nights at St. Lawrence
Email *
Youth's Name (First and Last) *
Youth's Shirt Size *
Youth's Grade (20-21 school year) *
Youth's Age *
Youth's Gender *
Parent/Guardian Name (First and Last) *
Home Address *
City *
Zip *
Parent/Guardian Cell *
Emergency Contact (Cannot Be A Parent) *
Emergency Contact Relationship to Youth (grandmother, family friend, etc.) *
Emergency Contact Phone Number *
Health Insurance Company *
Policy Number *
Name of Youth's Doctor *
Youth's Doctor's Phone *
Other medical or otherwise pertinent information
I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St. Lawrence, its officers, directors, employees and agents, and the Archdiocese of Mobile, its employees and agents, chaperones, or representatives associated with "Edge Nights", from any claim arising from or in connection with my child attending "Edge Nights" or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish/school/institution, its officers, directors and agents, and the Archdiocese of Mobile, its employees and agents and chaperones, or representative associated with the event for reasonable attorney’s fees and expenses that may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/school/institution/archdiocese. IN ADDITION, by signing this agreement, I acknowledge the contagious nature of COVID-19 and that my child(ren) and I may be exposed to or infected by COVID-19 by participating in the St. Lawrence activity and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at St. Lawrence may result from the actions, omissions, or negligence of myself and others, including, but not limited to, St. Lawrence employees, volunteers, and program participants and their families. Considering the foregoing, however, I grant permission for my child(ren) to participate in this parish activity at or near the parish site, notwithstanding the risks associated with the COVID-19 virus and group activities. I further agree on behalf of myself, my child named herein, and my spouse, our heirs, successors, and assigns, to release, indemnify, and hold harmless St. Lawrence and The Roman Catholic Church of the Archdiocese of Mobile, their members, directors, officers, employees, agents and representatives (“Indemnitees”) associated with the event arising from or in connection with the negligent acts or omissions of the Indemnitees ONLY in regard to prevention of the spread of the COVID-19 virus. I SPECIFICALLY ACKNOWLEDGE AND AGREE TO THE FOREGOING. *
Required
Enter your initials below to certify that you agree with the previously stated liability release *
A copy of your responses will be emailed to the address you provided.
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