ACTS Retreat Registration

Attendee Information
Name*
First Last
Preferred Name on Tag*
Which retreat are you registering for?*
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Physical Condition
Attendees 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).
Allergies
Please describe any medically perscribed dietary requirements.
Smoker?*
Previously been on ACTS Retreat?*
Shirt Size*
Emergency Contact
Name*
First Last
Relation*
Phone*
Email*
Parental Consent
Medical and Photo Release
- I agree
- I disagree
I 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.
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Attendee Information

Emergency Contact

Parental Consent