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Feb. 17-19_ 2012 OLMC CHAPERONE ... - Destination Jesus

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					         DESTINATION JESUS XVII - Feb. 17-19, 2012                                                                    PD____

                                                                                                                      CK____
           OLMC CHAPERONE INDIVIDUAL REGISTRATION FORM
               (Form to be filled out by all Chaperones above the age of 18 AND out of High School)                   LTR___


Each OLMC Chaperone attending the retreat must complete this form, sign the Liability & Medical Information/Release
portion, attach $10.00 T-shirt fee and submit all to the OLMC Youth Minister by Friday, January 20, 2012. Please do
not use any other liability or registration form.

NAME __________________________________________ MALE _____ FEMALE _____
AGE __________ PARISH                             OUR LADY OF MOUNT CARMEL___________________

HOME ADDRESS __________________________________________________________
CITY ______________________________________ ST ___________ ZIP _____________
PHONE________________________EMERGENCY PHONE#_______________________
DATE OF LAST DIOCESAN PROTOCOL TRAINING___________________________
PARISH YOUTH MINISTER NAME LOUIS PAIZ (PAIZL@OLMC1.ORG) – PHONE: (317) 846-3878
                       LIABILITY & MEDICAL INFORMATION/RELEASE

Accident/Hospitalization Policy Name _________________________________Policy Number__________________
Current Allergies_________________________________________________________________________________
Medical Conditions_______________________________________________________________________________
Medication Allergies______________________________________________________________________________

The undersigned hereby releases, forever discharges, and agrees to hold harmless Our Lady of Mt. Carmel Church &
The Diocese of Lafayette-in-Indiana from and against any and all liability, claims, demands, lawsuits and expenses of
any kind arising from personal injury, sickness, death, or property damage of any kind whatsoever which may be
incurred or suffered by the undersigned.

The undersigned further agrees to indemnify and hold harmless Our Lady of Mt. Carmel Church & The Diocese of
Lafayette-in-Indiana and its respective members, directors, employees and agents (collectively, the “Indemnities”) from
and against any and all claims, demands, actions, lawsuits, and liabilities, including attorney fees and expenses sustained
by the Indemnities as the result of negligent, willful or intentional acts of the undersigned.

The undersigned agrees not to transmit, distribute, or sell (or aid in transmitting, distributing, or selling) any description,
account, picture, video, audio or other form of reproduction of this event (in whole or in part). The undersigned grants
permission to Our Lady of Mt Carmel and the Diocese of Lafayette-in-Indiana to utilize the participants image, likeness,
actions and statements in any live or recorded audio, video, or photographic display or other transmission or reproduction,
in whole or in part, of the Destination Jesus Retreat event.

The undersigned hereby grants permission, in case of an emergency, to be taken to a physician or hospital by Destination
Jesus personnel. The undersigned hereby assumes all responsibility for any and all medical bills.



Participant’s Signature (Required) __________________________________________Date_______________
Participant’s Printed Name (Required)_______________________________________Date_______________


                                                                                                             Revised 11/16/11

				
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