Warhawk Catholic Spring Retreat

Registration Form

Name

University I attend

Phone Number

Sex

Male
Female

T-Shirt Size

Registration

I will be attending ($30.00)

Coupon Code

Meals: Dietary Needs and Allergies

Carpool Options:

PLEASE NOTE: Carpools will meet and depart from the Catholic Ministry Center (344 N Prairie St)

LIABILITY AND MEDICAL INFORMATION

Consent to Participate and Indemnity Agreement:

I consent to participate in this activity. I agree to reimburse and indemnify the Archdiocese of Milwaukee for all reasonable legal and court fees incurred by the archdiocese in defending a lawsuit that I may bring against the
archdiocese which relates to the above named activity if the archdiocese and/or it's agents are found not legally liable by the courts and prevails in the lawsuit. If the archdiocese is found legally liable for injuries sustained by me, this paragraph will not apply.

I certify that I have an understanding of this agreement and any risks and hazards associated with the activity described above that I will be participating in. I further understand that I had the opportunity to fully discuss this agreement with a representative of the archdiocese to clarify any concerns or questions about the activity or this agreement that I may have had.

I, the undersigned, agree to the terms above.

Medical Information

The following information will be used only in the event of an emergency in which you are unable to seek medical attention for yourself.

Physician's Name

Physician Phone #

Name of Medical Insurance

Policy Number

Medical Allergies, Mental/Physical Health Issues we should know in the event of an emergency:

I am taking medication and will bring all such medications necessary, and medications will be well labeled

By Checking this box I hereby warrant that to the best of my knowledge, I am in good health and I assume all responsibility for my health.*

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to be transported to a hospital for emergency medical treatment. I wish to have my spouse/parent advised prior to any further treatment by the hospital or doctor. In the event of emergency, please contact:

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to be transported to a hospital for emergency Emergency Medical Treatment: In the event of an emergency, I hereby give permission to be transported to a hospital for emergency medical
treatment. I wish to have my spouse/parent advised prior to any further treatment by the hospital or doctor. In the event of emergency, please
contact

Emergency Contact

Day Phone Number

Evening Phone Number

Cell Phone Number

Total

$0.00

Billing Information

Name

Credit Card

Visa
Mastercard
American Express
Discover

Address

Mobile Phone Number

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