Registration Ski/Tubing - Adult - St. Anthony Knoxville

Skiing/Tubing Registration & Consent - Adult

Name *

First

Last

Home Phone *

Address *

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Line 2

City

State

Zip Code

Country

Cell Phone *

Cell Phone Service Provider *

Email *

Special Needs/Health Concerns/Allergies *

* Indicates required field

Name of Medical Insurance Company *

Name of Policy Holder *

Policy/Group Number *

Emergency Contact Name *

First

Last

Emergency Contact Phone *

Authorization for Use of Name(s), Likeness(es), and/or Photographic Image(s) *

Yes No

I grant permission to St. Anthony Catholic Church to use my name, likeness, and/or photographic image(s) in the production of parish and/or diocesan newsletters, bulletins, websites, posters, bulletin boards, slide shows and other parish or diocesan promotional materials and in articles about the parish that may be published in local or diocesan newspapers. I further understand that St. Anthony Catholic Church is not responsible for access to the Internet information or downloads made by users using the web prior to removal of web references and that my name, likeness or image(s) may be used in any publication already printed or published prior to removal by St. Anthony Catholic Church.

Statement of Consent & Liability Release *

I give permission to be transported to and to participate in the above mentioned activity, coordinated by St. Anthony Catholic Church. In the event of sickness or accident, the adult(s) supervising this activity have my permission to secure medical care for me.

I hereby release St. Anthony Catholic Church, its employees and volunteers, and any affiliated deanery or diocesan employees and volunteers from any and all claims arising out of or from any accident or other occurrence, causing injury to any person or property, during this event. If I become injured or ill, and my emergency contact cannot be reached, I authorize for myself all surgical, x-ray, laboratory, anesthesia, and/or other medical procedures as may be performed or prescribed by the attending physician and/or emergency personnel. I accept responsibility for all medical/surgical treatment charges, which may be incurred.

Please note, by typing your name and date below you are providing your electronic signature for this "Statement of Consent & Liability Release."

Signature *

Date *

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