Confirmation Retreat Registration 2019
Location: Halquist Lodge at Camp Minikani, Hubertus 875 Amy Belle Rd, Hubertus, WI 53033
(https://www.stjames-parish.com/wp-content/uploads/2018/12/Camp-Minikani-Map.pdf)
Do NOT turn on Amy Belle Lake Rd.
Look for the big STONE "Camp Minikani" sign at the entrance to the camp

Parents will drop off and pick up their own children to Halquist Lodge at Camp Minikani in Hubertus

Arrival Time: Saturday, February 2nd, Noon at Camp Minikani in Hubertus
Pick up time: Sunday, February 3rd, 4:00pm at Camp Minikani in Hubertus

Please complete this registration by Sunday, January 13th

Cost: $100 per person; checks made payable to St. James and delivered to either Good Shepherd or St. James CF Office or mailed:
St. James
ATTN: Bryan Ramsey
W220 N6588 Townline Rd.
Menomonee Falls, WI 53051

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 *
Your answer
Last Name *
Your answer
Parish or Friend Of *
Parent/ Guardian First Name *
Your answer
Parent/ Guardian Last Name *
Your answer
Alternate Email
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
Would you like to chaperone or help with meal prep/cleanup? (Please indicate best way (email, phone) to reach you in "other" box if you are willing to help out)
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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