Retreatant's Name*
First
Last
Date of birth* Register Second Child Retreatant's Name*
First
Last
Date of birth* Register Third Child Retreatant's Name*
First
Last
Date of birth*
Parent Information Home Address*
Billing Address*
Same as home address
Street Address
Address Line 2
City
State
ZIP Code
AUTHORIZATION: I/We hereby authorize Miles Christi to use the image and likeness of me/us or my/our child in photograph or video form whether taken by or commissioned by Miles Christi in its promotional materials and for its promotional purposes associated with its nonprofit activities. This authorization shall extend to use of my/our or my/our child’s image and likeness on the website of Miles Christi, or its successor in operation or affiliated organization(s) upon written consent of Miles Christi. I/We understand that this authorization shall survive the end of my/our or my/our child’s participation in the activities referenced on this form.
RELEASE AND INDEMNIFICATION: I/WE AGREE TO RELEASE, WAIVE, FOREVER DISCHARGE, HOLD HARMLESS, INDEMNIFY AND DEFEND MILES CHRISTI AND ANY OF ITS PRIESTS, BROTHERS, OFFICERS, DIRECTORS, AGENTS, SERVANTS, EMPLOYEES, REPRESENTATIVES, ASSIGNS AND/OR SUCCESSORS FROM AND AGAINST ANY AND ALL LIABILITY, CLAIMS, DEMANDS, SUITS, ACTIONS, LOSSES AND DAMAGES OF WHATEVER KIND OR NATURE EITHER IN LAW OR EQUITY, INCLUDING, BUT NOT LIMITED TO (A) NEGLIGENCE, INCLUDING THE ACTIVE OR PASSIVE NEGLIGENCE OF MILES CHRISTI, ITS PRIESTS, BROTHERS, OFFICERS, DIRECTORS, AGENTS, SERVANTS, EMPLOYEES, REPRESENTATIVES, ASSIGNS AND/OR SUCCESSORS; (B) BREACH OF CONTRACT; (C) BREACH OF ANY STATUTORY DUTY OR OTHER DUTY OF CARE; (D) BREACH OF EXPRESS OR IMPLIED WARRANTY; OR (E) ANY OTHER CAUSE, RESULTING IN PERSONAL INJURY, DEATH OR PROPERTY DAMAGE AND ARISING FROM MY OR THE MINOR’S PARTICIPATION IN THE EVENT OR AT ANY FACILITY OWNED OR OPERATED BY MILES CHRISTI, ITS PRIESTS, BROTHERS, OFFICERS, DIRECTORS, AGENTS, SERVANTS, EMPLOYEES, REPRESENTATIVES, ASSIGNS AND/OR SUCCESSORS. IN CONSIDERATION OF ME/US OR MY/OUR CHILD BEING PERMITTED TO PARTICIPATE IN THE EVENT, I/WE HEREBY AGREE TO INDEMNIFY, DEFEND AND HOLD MILES CHRISTI, AND ANY OF ITS PRIESTS, BROTHERS, OFFICERS, DIRECTORS, AGENTS, SERVANTS, EMPLOYEES, REPRESENTATIVES, ASSIGNS AND/OR SUCCESSORS, HARMLESS FROM AND AGAINST ANY AND ALL LIABILITY, DAMAGE, LOSS, COST AND EXPENSE INCURRED AS A RESULT OF ANY CLAIM, DEMAND, OR CAUSE OF ACTION, BROUGHT AGAINST MILES CHRISTI, OR ANY OF ITS PRIESTS, BROTHERS, OFFICERS, DIRECTORS, AGENTS, SERVANTS, EMPLOYEES, REPRESENTATIVES, ASSIGNS AND/OR SUCCESSORS, JOINTLY OR INDIVIDUALLY, FOR BODILY OR OTHER INJURY OR PROPERTY DAMAGE SUFFERED AS A RESULT OF MY/US OR MY/OUR CHILD’S PARTICIPATION IN THE EVENT. I/WE AGREE THAT IF ANY PROVISION OF THIS PARAGRAPH IS FOUND INVALID OR UNENFORCEABLE BY A COURT OF COMPETENT JURISDICTION, THAT PROVISION SHALL BE AMENDED TO ACHIEVE AS NEARLY AS POSSIBLE, CONSISTENT WITH APPLICABLE LAW, THE MAXIMUM PERMISSIBLE EFFECT AS THE ORIGINAL PROVISION, AND THE REMAINDER OF THIS PARAGRAPH SHALL REMAIN IN FULL FORCE AND EFFECT.
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Liability Waiver* This field is hidden when viewing the form
Electronic Signature*
By typing my full name in the box above, I agree that I am the parent/legal guardian of the participant and consider this as my electronic signature which is valid in a court of law.
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Untitled This field is hidden when viewing the form
Untitled* In case of an emergency I authorize Miles Christi or its representatives to bring my child to the nearest medical facility. I understand that I will be liable for all cost incurred by any medical emergency that is needed by my child.
Emergency Contact Name*
First
Last
Payment Information How many total children are you registering today? Credit Card* 
