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Check Payment Registration Form

Please fill out the form below and mail your check as soon as you can. Thank you!

Cost and Registration
Cost: $199 on or before May 17. Price will then increase to $225.
Registrations close on June 28.

Mailing Address
Please make check out to:

Miles Christi Family Center
25300 Johns Road
South Lyon, MI 48178

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 size

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About
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