Fall 2018 Antioch CM Registration Form
Oct 5th-7th

The COST: $10.00

All payments need to be paid by check or cash.

Name
Your answer
Age
Your answer
Gender
T-Shirt Size
Your answer
Times I will DEFINITELY be at the retreat!
Your answer
I can be the second person in transporting to the host homes.
Address
Your answer
Cell Phone Number
Your answer
Email address
Your answer
Emergency Contact
Your answer
Food Allergies
Your answer
I have completed the online Diocesan Protocol Training, "Safe and Sacred"
Date of Completion and Parish where you are registered
Your answer
Waiver
I hereby consent and agree to hold harmless Saint Lawrence Catholic Church and/or the Roman Catholic Diocese of Lafayette-in-Indiana, Inc., and any and all employees or volunteers thereof, for any accident, injury or occurrence arising out of, or in connection with the aforementioned activity.
I have read the above and waiver and agree to the terms within.
Medical
I give my permission, in case of an emergency, to be taken to a physician or hospital by an adult retreat member. I hereby give permission to the physician selected by the adult retreat member to secure proper treatment for myself.
I have read the above statement and agree to the terms within.
Submit
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