Name* First Last Date of birth* MM slash DD slash YYYY Grade* Parents' names Street Address* Street Address Address Line 2 City State ZIP Code Billing Address* Same as home address Street Address Address Line 2 City State ZIP Code Phone*Camper's email Parent's email* 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. Liability Waiver* By clicking this box I acknowledge that I am over the age of 18 and that I have read and understand the above permission form in its entirety, and also understand that it is a legal document and I agree and consent to all terms and conditions contained within. 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.Medical conditions/medications taken Name of Insurance Company Insurance Policy # or Plan Untitled We currently do not carry insurance. We will bring a printed copy of the insurance information 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. I accept Emergency contact name* First Last Emergency contact phone*Allergies Dietary restrictions Shirt size* Small Medium Large X-Large Transportation My parents will take me to Holy Rosary Parish and pick me up from there I will need a ride! (We will contact you to make carpool arrangements) My parents would like to help with carpooling My parents would like to help with transportation during the camping trip (going from the Parish to the different destinations for excursions). We will contact you for more details. I will need a ride! Both ways From South Lyon to Cedar only From Cedar back to South Lyon only My parents would like to help with carpooling We can help drive both ways We can help drive from South Lyon to Cedar We can help drive from Cedar back to South Lyon Tents* I can bring a tent I need a tent Tent size1-23-45-67-8Additional donation (optional) Please consider making a donation that would help to cover expenses for this trip, or even help another boy who might not otherwise be able to attend.