Summer Camp additional registration

MI Girls Summer Camp Registration

"*" indicates required fields

Registration

Name*

First Last

Date of birth*

MM slash DD slash YYYY

Camper's email

School Name

Grade*

Medical conditions/medications taken

Allergies/Dietary Restrictions

Shirt size (unisex)*

Small

Medium

Large

Add Child

Name*

First Last

Date of birth*

MM slash DD slash YYYY

Camper's email

School Name

Grade*

Medical conditions/medications taken

Allergies/Dietary Restrictions

Shirt size (unisex)*

Small

Medium

Large

Add Child

Name*

First Last

Date of birth*

MM slash DD slash YYYY

Camper's email

School Name

Grade*

Medical conditions/medications taken

Allergies/Dietary Restrictions

Shirt size (unisex)*

Small

Medium

Large

Parent Information

Parents' Names*

Parish

Home 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*

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.

Name of Insurance Company

Insurance Policy # or Plan

Untitled

We do not carry insurance.

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*

Payment Information

Please enter the number of children you are registering Quantity*

Price: $250.00

Quantity

Help Miles Christi cover the online credit card transaction fee (3%)*

Additional donation (optional)

Coupon

Total

Credit Card*

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Cardholder Name

Summer Camp additional registration

MI Girls Summer Camp Registration

Registration

Parent Information

Payment Information

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