"RESTORED": “Restore us, O God; let thy face shine, that we may be saved.” - Psalm 80:3
Event Date: July 23-25
Event Location: Mayo Civic Center, Rochester, MN
Contact Cody: cklamm@saintsppta.org or 612.354.6313
Chaperone Name *
Gender *
Age *
Required
Chaperone Phone #
Address, City, St, & Zip *
Chaperone Email *
Medications/Allergies/Other Notables
Consent Agreement
I, the Adult Chaperone registered to attend Steubenville with the 3SaintsYouth program from July 23-25 at Mayo Civic Center in Rochester, MN hereby agrees to indemnify and hold harmless, to the furthest extent permitted by law, the Archdiocese of St. Paul and Minneapolis, Ss. Peter & Paul Catholic Church, the City of Loretto, MN, St. Thomas the Apostle Catholic Church, the City of Corcoran, MN, and any and all of its/their employees, supervisors, and/or youth from any harm, claim for damages, cause of action, lawsuit or other legal proceeding resulting from the injury or death of any participant.

Further, in the event of injury to myself I hereby grant authorized medical professionals the right to administer necessary emergency treatment.
Media Consent
Should photos or video be taken, I give my permission for the use of the image and/or likeness of my person in any promotional or other marketing activities relating to the event/activity or our parish Youth Ministry without compensation to me.

If you do not want your image and/or likeness to be used to promote parish youth ministry events, contact the parish office to receive a version of this form that does not include the previous clause; however, some events/activities may require this clause.
If you agree to adhere to the above "consent agreement" & "media consent" click agree *
If you agree to submit a payment approx. $94-$100 for the hotel arrangements please click agree. If you have issues with this click: I have issues. *
Chaperone Name for Consent *
Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy