Attendee InformationName* First Last Preferred Name on Tag*Which retreat are you registering for?*Teen's ACTS RetreatWomen's ACTS RetreatMen's ACTS RetreatAre you a St. Patrick's Parishioner?*YesNoWhich parish are you from?*Date of Birth* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email*Physical ConditionAttendees must be able to participate in mild physical activity for 1 to 2 hours, including sitting or standing for more than an hour at a time, climbing stairs, and walking on uneven and/or varied terrain. Please describe any problems that may effect your ability to participate (for example: heart problems, allergies, medications, or mobility issues). AllergiesPlease describe any medically perscribed dietary requirements.Smoker?*YesNoPreviously been on ACTS Retreat?*YesNoShirt Size*X SmallSmallMediumLargeX LargeEmergency ContactName* First Last Relation*Phone*Email* Parental ConsentMedical and Photo ReleaseI agreeI disagreeI understand that reasonable precautions will be taken to safeguard the health and well being of the participants in this ACTS and that I will be notified as soon as possible in the event of an emergency. In the case of sickness or an accident, I authorize and consent the ACTS Team, or other associated volunteers of the ACTS program to obtain medical care from a licensed physician, hospital, or medical clinic for my son/daughter in the event that myself or other legal guardian(s) cannot be reached. I hereby do release and forever discharge this Diocese, and Parish from all manners of actions, claims which I or the child named above shall or may have for any reason, arising during my child’s attendance of the ACTS Retreat. Unless other written instruction is submitted, I also consent to allowing my child’s image to be recorded, either by photograph or video, and used during the ACTS Retreat or for future advertisement of Parish ACTS programs. Any other use will require your further consent.CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.
