2014 CFC-Youth Precon

June 21,2014
St. Joseph Parish

Registration Form
CFC Region:______________________________
Name:___________________,
_________________
Last Name

Shirt Size: XL

___________________________
First Name

Street Address

_______

M.I.

Address:_____________________________________
_____________

Nickname

______________________
City

Zip Code

Phone/Cell phone:______/________/__________
Email:_________________________________________
Birthday:______/______/_________

Age:_______

Gender:

Male Female

Parent/Guardians Name: ______________________________ Contact Phone:______/______/_________

______________________________ Contact
Phone:______/______/_________

Medical
Medications:____________________________________________________________________________
Physical Limitations/Food Allergies:_______________________________________________________
Medical Condition:_______________________ Health Insurance Carrier:__________________________
Policy Number: __________________________ Cardholders Name:_______________________________
Primary Care Doctor:_____________________ Doctors Phone:___________________________________
I, the undersigned ( participant | parent of youth | guardian of youth) hereby acknowledge that on
June 21, 2014, the participant, whose name appears above, is scheduled to take a trip to St Joseph
Catholic Church in St. Louis, MO for the event arranged by the Couples for Christ-Youth. In the event of an
emergency, I hereby give permission to transport the participant to a hospital for emergency medical,
dental, anesthetic or surgical treatment. I agree to pay for any expenses incurred for such treatment. I
hereby release, indemnify, and hold harmless the Couples for Christ or any parish thereof, its employees,

ministries, agents, representatives, affiliates, and volunteers from any and all demands, claims, injury, and
liability arising out of the participants action in the program. I hereby waive my claim to a lawsuit against
the Couples for Christ, the Diocese of Saint Louis and any such persons for any liability arising out of the
participants action in this activity. I further acknowledge that any injury or loss, regardless of severity, is
required to be reported to the parish.
Signature: _________________________________

Father Mother Guardian Self

Consent/ Waiver Form

I, the undersigned Parent and/or Guardian of the Child, whose name appears below,
hereby give consent for the Participant to attend the Couples For Christ Youth Precon
which will be held at the St. Joseph Parish. In the event of any injury to the participant,
this document fully releases Couples For Christ Youth and all its members from any of
the liability and/or responsibility, which are not covered under the policy held by the
mentioned.
I understand that each of the participants will be provided constant adult supervision. I
herby authorize Couples For Christ Youth to arrange for my childs medical attention,
diagnosis, treatment, and hospitalization and care in case of emergency, as deemed
advisable by a certified physician, and/or paramedic responding to an emergency (911)
call, after an unsuccessful effort has been made to contact the undersigned or my
designated representative.
Couples for Christ Youth is, therefore, fully absolved and released from any responsibility
and/or liability from my child while engaged in any of the activities within the scope of the
program. I agree and understand that I hold harmless, Couples for Christ Youth from all
or any liabilities, cost, and damage to a property caused by or arising out of my childs
participation in this conference.
Participant Name_________________________________________________
Parent/Guardian Name_________________________________________________
Participant Signature or Parent if under
18_______________________________________
Date: Sat, June 21, 2014
Time: 8:30 am to 7:00 pm
Fee: $15.00 (due at the door)
Venue: St. Joseph Parish
567 St. Joseph Ln.
Manchester, MO 63021
CFC Youth Couple Coordinators
Rommel Romero: (314) 527-9741
Elena Romero: (314) 449-3511

NOTE: Please submit this form to yfcmo2014@gmail.com