CHWC Adult Registration

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- Event: Catholic Heart Workcamp
  Dates: June 7 - June 14, 2025
  Time: Departing SVDP at 10am on Saturday, June 7th. Arriving back to SVDP at approx. 5pm on Saturday, June 14th.
  Location: St. Benedict of Auburndale Catholic School, Memphis, TN
  
  Cost for Adults: Free
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- RELEASE OF LIABILITY, INDEMNIFICATION AGREEMENT & MEDICAL RELEASE
  I, [NAME stated above], agree on behalf of myself, my heirs, assigns, executors, and personal representatives, to hold harmless, and defend St. Vincent de Paul Catholic Church, the Archdiocese of Saint Paul and Minneapolis, its officers, directors, agents, employees and representatives (“Releasees”) associated with the Event from any and all liability claims, injury, loss and damage arising from or in connection with my participation in the Event.
  
  Further, I AGREE to hold Releasees harmless and indemnify Releasees for any claim or cause of action whatsoever, including but not limited to all claims relating to communicable disease, arising out of the above Activity which takes place during the above identified dates that is brought against Releasees by myself or my family members, heirs, assigns, executors, and personal representatives.
  
  I UNDERSTAND that participation in the described activity involves danger and risk of injury. The inherent danger is understood and voluntarily assumed.
- I Agree Please select this field.
- EMERGENCY MEDICAL TREATMENT: If I should require medical treatment and I am not able to communicate my desires to attending physicians or other medical personnel, I give permission for the necessary emergency treatment to be administered.
- Please advise the doctors that I have the following allergies and/or other health conditions:
- EMERGENCY CONTACT
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Relation to me REQUIRED Please fill out this field. Please enter valid data.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Health Insurance Carrier Please enter valid data.
- Insurance Policy Number Please enter valid data.
- Insurance Group Number Please enter valid data.
- I HAVE READ THIS DOCUMENT. I UNDERSTAND IT IS AN AUTHORIZATION FOR MEDICAL TREATMENT, INDEMNIFICATION AGREEMENT AND RELEASE OF ALL CLAIMS. I UNDERSTAND I ASSUME ALL RISK INHERENT IN THIS ACTIVITY. I VOLUNTARILY SIGN MY NAME EVIDENCING MY ACCEPTANCE OF THESE PROVISIONS.
- Electronic Signature REQUIRED Please fill out this field. Please enter valid data.
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CHWC Adult Registration

RELEASE OF LIABILITY, INDEMNIFICATION AGREEMENT & MEDICAL RELEASE