Middle School Girls Lock In 2019
Event Timing: May 24, 2019 7pm--May 25, 2019 12pm
Cost: $20 includes (T Shirt, Snacks, Breakfast and Lunch)
Event Address: Parish Hall & Youth Upper Room in Parish Office 7800 Halprin Dr., Norfolk, VA 23518
Contact Mrs. Aponte at (757) 583-0291 x 18 or youth@piusxparish.org
Email address *
Youth Name *
Your answer
Grade *
Dietary restrictions *
T Shirt (Adult) Size *
Required
Additional Youth Name
Your answer
Grade
Dietary restrictions
T Shirt (Adult) Size
Parent/ Guardian Name *
Your answer
Cell Phone # *
Your answer
Parent/ Guardian Name *
Your answer
Cell Phone #
Your answer
Contact in case of EMERGENCY *
Your answer
Emergency Phone Number *
Your answer
Release of Liability and Medical Release
As parent and/or legal guardian I remain legally responsible for any personal actions taken by the above named minor. I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St. Pius X and the Catholic Diocese of Richmond, its employees and agents, chaperons, or representatives associated with this event from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the Diocese, its employees and agents and chaperons, or representatives associated with the event for reasonable attorney’s fees and expenses which 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 Diocese. I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. In the event of any emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers I give permission for the noted emergency contact to be notified. I will not hold St. Pius X and the Diocese of Richmond responsible for authorizing any medical treatment beyond necessary transportation to the hospital.
Release of Liability and Medical Release *
Required
Use of Pictures and/or Video
I give permission for pictures and/or video of my child (named above) engaged in activities related to the parish or Diocesan event to have their pictures posted in St. Pius X the Diocese of Richmond publications or websites. Names of participants will not be used without expressed permission from the parent or guardian. If no box is checked below, the Diocese of Richmond assumes you give permission.
Use of Pictures and/or Video *
Required
I understand that I will have to pay $20 upon arrival (Checks payable to: St. Pius X) *
Required
Parent / Guardian Electronic Signature *
Your answer
A copy of your responses will be emailed to the address you provided.
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