Campton Mission Adult Registration Form

CAMPTON MISSION ADULT REGISTRATION FORM 2022

1. I, the undersigned, will participate in the activity described on the Activity Information Form (the “Activity”) and release from all liability, indemnify, and hold harmless _St. John the Evangelist, West Chester____(print name of parish and school) (“Parish and School”), the Archdiocese of Cincinnati (the “Archdiocese”), the Archbishop of Cincinnati (the “Archbishop”), both individually and as trustee for the Archdiocese, all parishes and schools within the Archdiocese, and all of their agents, representatives, volunteers, and employees from any and all liability, claims, judgments, damages, costs and expenses, including attorneys’ fees, arising out of any injury, illness, infectious and/or communicable disease (such as MRSA, influenza, or COVID-19), or death, (including any injury, illness, infectious and/or communicable disease, or death caused by the negligence of Parish and School, the Archbishop, the Archdiocese, any parish or school within the Archdiocese, or any of their agents, representatives, volunteers, or employees) incurred by me while participating in the Activity, traveling to or from the Activity, or while using the facilities and equipment of the Parish and School. I further agree not to bring or prosecute or allow to be brought or prosecuted (including, but not limited to, prosecution through subrogation) in my name any claims, lawsuits, or actions against Parish and School, the Archbishop, the Archdiocese, all parishes and schools within the Archdiocese, or their agents, representatives, volunteers, and employees.

2. I understand that my participation in the Activity is purely voluntary and is a privilege and not a right, and that I agree to participate in the Activity in spite of the risks of injury, illness, infectious and/or communicable disease (such as MRSA, influenza, or COVID-19), and death. If I have underlying health concerns which may place me at greater risk of contracting COVID-19 or that would possibly increase the severity of illness if COVID-19 is contracted, then I agree to consult with a health care professional before participating in the Activity.

3. I agree to cooperate with the agents of Parish and School and/or the Archdiocese who are in charge of the Activity.

4. I authorize the agents of Parish and School and/or the Archdiocese who are acting as leaders of the Activity to seek medical treatment for me in the event of any injury, illness, or medical emergency during the Activity or related travel. I understand that the agents of Parish and School and/or the Archdiocese will make a reasonable attempt to contact the individual listed below as my emergency contact as soon as possible in the event of a medical emergency.

* Indicates required field

5. PLEASE INDICATE. THE PARISH AND SCHOOL AND/OR THE ARCHDIOCESE MAY USE MY PORTRAIT OR PHOTOGRAPH FOR PROMOTIONAL PURPOSES, WEBSITE, AND OFFICE FUNCTIONS. *

I agree. I do not agree.

6. THE PARISH AND SCHOOL AND/OR THE ARCHDIOCESE MAY USE SOCIAL MEDIA AND TECHNOLOGY TO COMMUNICATE WITH ME REGARDING PARISH/SCHOOL RELATED MINISTRY ACTIVITIES. *

I agree. I do not agree.

7. This Permission, Release, and Authorization is intended to be as broad and inclusive as permitted by the law of the State of Ohio, and if any portion hereof is declared invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This Permission, Release, and Authorization shall be construed in accordance with the laws of the State of Ohio, excluding, and irrespective of, any choice of law principles to the contrary.

8. Parish and School, the Archdiocese, the Archbishop and their agents, employees, and volunteers shall have no liability whatsoever in the event the Activity is cancelled due, in whole or in part, to any present or future pandemic, epidemic, widespread disease or illness, public health concern, or circumstances arising therefrom, or from actions taken by any governmental or municipal authority to prevent, avoid, or mitigate the impacts thereof.

9. I have carefully read and understand and accept the terms and conditions stated herein and I acknowledge and agree that this Permission, Release, and Authorization to Seek Medical Treatment shall be effective and binding upon me and my personal representatives, estates, assigns, heirs, and next of kin. I have signed below of my own free will.

Name *

First

Last

Birth date *

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Spouse/Partner Name *

Spouse/partner phone number *

Employment *

Address of employment *

Line 1

Line 2

City

State

Zip Code

Country

MEDICATIONS/ALLERGIES/DISORDERS/CHRONIC CONDITIONS *

MEDICAL INSURANCE COMPANY *

MEMBER NUMBER FOR MEDICAL INSURANCE *

member's name *

member's phone number *

doctor *

doctor's Phone Number *

emergency contact *

relationship to emergency contact *

emergency contact phone number *

T SHIRT SIZE (SELECT ONE) *

SWIMMING CAPABILITY *

SPECIAL SKILLS (MUSIC, BUILDING, ART, ETC.) *

signature *

date *

IN ADDITION TO MEDICAL INFORMATION, A $50 REGISTRATION FEE IS NEEDED FOR EACH VOLUNTEER. CHECKS CAN BE MADE PAYABLE TO “ST. JOHN THE EVANGELIST” WITH “CAMPTON FEE” IN THE MEMO LINE, OR YOU CAN PAY ONLINE HERE. ONCE REGISTERED, ALL VOLUNTEERS ARE REQUIRED TO ATTEND TWO INFORMATION SESSIONS. MORE INFORMATION TO COME.

Submit

​CAMPTON MISSION ADULT REGISTRATION FORM 2022

CAMPTON MISSION ADULT REGISTRATION FORM 2022