2024 Mission Trip Registration

Name

Address

This address will receive a confirmation email

Cell Phone

Secondary Phone

Gender

Male Female

Date of Birth

Age

18-20 21 or over

**Note: Young adults (18-20) may participate as part of a parish’s adult team for training purposes, but may not be counted as an official chaperone for the adult / youth ratio.

Are you a parent of a youth participant?

Yes No

If yes, do you prefer to be with your child when possible or not? Please explain.

The mode of transportation for Alive In You is personal and/or rented vehicles which can, preferrably, carry 7 or 8 people. (12-15 passenger vans are NOT allowed)

Do you have a personal vehicle which can be used to transport teens and adults for this trip?

Yes No

If you answered "yes," how many seatbelts does your vehicle have?

Emergency Contacts

Main Emergency Contact Name

Main Emergency Contact Phone

Other Emergency Contact Name

Other Emergency Contact Phone

Medical Information

The information below is requested, but not required. It will only be used in the case of an emergency.

Insurance Carrier

Insurance Policy #

Insurance Phone Number

Name of Insurance Holder

Relationship of Holder to you

Please list below the names of medications taken on a regular basis:

Allergic reactions (medications, foods, plants, insects, etc.)

Immunizations (date of last tetanus/diphtheria)

Any disabilities or physical limitations

Any other special medical conditions

Consent to Participate & Liability Release

In consideration for allowing me to participate in this activity, I assume all risks and hazards incidental to my participation in the Event, including transportation to and from the Event. In consideration for allowing me to participate in the event listed above, and on behalf of myself and my parents, legal guardians, siblings, heirs, assigns, and personal representatives, I hereby release and agree to fully and unconditionally protect, indemnify, and defend the Parish, the Roman Catholic Diocese of Dallas, and their respective officers, agents, and employees, (collectively, “Indemnitees”) and hold each Indemnitee harmless from and against any and all costs, expenses, attorney’s fees, claims damages, demands, suits, judgments, losses, or liability for injuries to property, injuries to persons, and from any other costs, expenses, attorney fees, claims, suits judgments, losses, or liabilities of any and every nature whatsoever arising in any manner, directly or indirectly, out of, in connection with, in the course of, or incidental to my participation in the Event, REGARDLESS OF CAUSE OR OF THE JOINT, COMPARATIVE OR CONCURRENT NEGLIGENCE OF THE INDEMNITEES. In the event any legal action is taken by either party against the other party to enforce any of the terms and conditions of this release, it is agreed that the unsuccessful party to such action shall pay to the prevailing party therein all reasonable court costs, attorneys’ fees, and expenses incurred by the prevailing party.

I have read this consent & liability release, & I understand & voluntarily agree to its provisions.

Media Consent & Social Media Communications

On occasion, video recordings, audio recordings, photographic slides, and photographs are taken of children and youth during church and diocesan sponsored activities. These are utilized in newsletters, websites, event promotion, advertisements and other printed media. As the State of Texas does not prevent audio or video recording or the photographing of children/youth For good and valuable consideration, I hereby grant to Our Lady of Angels Catholic Church the irrevocable and unrestricted right to make, use and/or publish any and all photographs, videos, and other images of me/my minor child or images in which Student may be included, now existing or hereafter made, in any case, with or without identifying Student for editorial, advertising, news, or any other purpose and in any manner and medium; to alter the same without restriction; and to copyright the same. On behalf of myself and/or my child, I specifically waive all rights to privacy and confidentiality with respect to name, likeness, voice, photographs, images, video recordings, audio recordings and identifying information. I hereby release and agree to fully and unconditionally protect, indemnify, and defend Our Lady of Angels, the Roman Catholic Diocese of Dallas, and their respective officers, agents, and employees, (collectively, “Indemnitees”) and hold each Indemnitee harmless from and against any and all costs, expenses, attorney’s fees, claims damages, demands, suits, judgments, losses, or liability for injuries to property, injuries to persons (including Student) and from any other costs, expenses, attorney fees, claims, suits judgments, losses, or liabilities of any and every nature whatsoever arising in any manner, directly or indirectly, out of, in connection with, in the course of, or incidental to the use or publication of any photographs, videos, or other images of Student, REGARDLESS OF CAUSE OR OF THE JOINT, COMPARATIVE, OR CONCURRENT NEGLIGENCE OF THE INDEMNITEES.

I have read this consent for Media Release, & I understand and voluntarily agree to its provisions.

Expenses for Young Adults 18-20

Young Adults age 18-20 must be cleared to participate, but are not allowed to be chaperones or drivers. Therefore, the fee for them is $590. You may pay in full or as follows:

Due Oct. 25 or with registration: Deposit, $130
Due Nov. 25: Installment 1, $115
Due Jan. 25: Installment 2, $115
Due Feb. 25: Installment 3, $115
Due Mar. 25: Installment 4, $115

Payment for 18-20 Year Olds

Electronic Signature for Agreements

Name of person giving above consents

To make your electronic signature type your initials followed by 4 digits such as your date of birth or other unique ID number (EX: ABC1234)

Questions/Comments for YM Staff

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2024 Mission Trip Registration - ADULTS

Description

2024 Mission Trip Registration - ADULTS

Description

Please Fix the Following