2019 ADULT REGISTRATION- Echoes of Worth
Details
Location: Mission Springs Retreat Center
Address: 1050 Lockhart Gulch Road, Scotts Valley, CA 95066
Contact Name: Andrew Brown
Dates: Friday, January 18 to Sunday, January 20, 2019.
A multi-parish, multi-diocese weekend with guest speakers, music, Mass, workshops, small groups, prayer experiences, and more.
Email address *
First Name *
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Last Name *
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Home Address *
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E-mail Address *
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Shirt size *
Gender *
Parish Name *
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Parish Youth Minister Name
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Parish Youth Minister Email address
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Medical plan name *
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Policy number *
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Medical plan address *
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Medical plan telephone *
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Doctor's name *
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Doctor's telephone *
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Emergency contact name *
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Emergency contact telephone *
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Fingerprint Clearance- Have you received fingerprinting clearance from your diocese to work with children and vulnerable adults? *
If NO to the previous question are you open to getting fingerprinted through the approved diocesan standards?
Safe Environment- Are you cleared within your diocese to serve with young people as outlined in the Charter for the Protection of Children and Vulnerable Adults? *
If NO to the previous question are you open to completing the necessary training (online) to be certified to work with youth?
I hold the parish and Diocese of San Jose harmless from any claim of injury, sickness, illness or damage that I may suffer or sustain during the ACTIVITY listed above, with exception to injury of damages arising out of the sole negligence of the parish or Diocese of San Jose.I attest that i AM physically fit to participate in this event.In the event THAT I become ill or injured, i do hereby consent to whatever x-ray, examination, medical or treatment and hospital care are considered necessary in the best judgement of the attending physicain and performed by or under the supervisoin of a member of the medical staff of the hospital facility providing the treatment. I am not aware of any medical condition which would render it inappropriate for me to participate in any such activity. *
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OCCASIONALLY PICTURES ARE TAKEN OF YOUTH MINISTRY EVENTS AND GATHERINGS. WE WOULD LIKE TO BE ABLE TO USE THESE PHOTOGRAPHS FOR NEWSLETTERS, FLYERS, AND THE ECHOES OF WORTH WEB SITE. WE WILL NOT USE ANY LAST NAMES IF POSTED. CONCERNS ABOUT PUBLISHED PICTURES SHOULD BE EXPRESSED TO WRITER/ WEBMASTER AND WILL BE PROMPTLY DEALT WITH. I AUTHORIZE AND GIVE FULL CONSENT, WITHOUT LIMITATION OR RESERVATION, TO THE ECHOES OF WORTH TEAM TO PUBLISH ANY PHOTOGRAPHS IN WHICH THE ABOVE NAMED PARTICIPANT AND/OR PICTURES APPEARS WHILE PARTICIPATING IN ANY PROGRAM WITH ECHOES OF WORTH. NO COMPENSATION IS TO BE GIVEN. *
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Are there any known allergies to food that we should be aware of? If yes, please explain. If no, please leave blank.
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Do you have any known allergies to medications that we should be aware of? If yes, please explain. If no, please leave blank.
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Do you have any special dietary needs? If yes please list.
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Do you have any known physical, psychological or emotional limitations that would affect your participation in this event?
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