Family Name

Home Phone Number

Cell Phone Number

Street Address

City

State

Zip Code

Email Address

Emergency Contact (name & phone)

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Special Request

Liability Waiver: Liability Waiver: In consideration of the opportunity for my family to participate in the program. I agree to release and hold harmless and indemnify Saint Katharine Drexel, Frederick MD. The Roman Catholic Archbishop of Baltimore and his successors, a Corporation Sole, and all their agents, servants and employees from liability, claims, demands and causes of action arising out of relating to any loss, damage or injury sustained in connection with or arising out of participation in the Program.

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Photography Release: Photography Release: I understand and grant permission that photographs or videotapes of participants may be used in publications, websites or other materials produced from time to time. Participants will not be identified unless we obtain specific written consent. Please note that we do not have control over the use of photographs or film taken by any media source that may cover the event.

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Medical Release: Medical Release: Medical Release: I hereby grant permission to any staff person to obtain medical care from a licensed physician, hospital, or medical clinic for my son or daughter in the event that I am not present. I am covered by hospitalization and medical insurance under policy listed below.

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Provider and Policy#

Medical Responsibility: Medical Responsibility: I do not have medical coverage and assume responsibility for the cost of hospitalization and medical care for my son/daughter.

Choose Response Choose ResponseI assume medical responsibilityI do not assume responsibility, use provider and policy listed above