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Adult Liability

- Church

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- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name 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.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Event REQUIRED Please fill out this field. Please enter valid data.
- Cell Phone Number REQUIRED
  
  Please fill out this field. Please enter a phone number.
- In case of emergency please contact REQUIRED Please fill out this field. Please enter valid data.
- Relationship to person above REQUIRED Please fill out this field. Please enter valid data.
- Phone Number for emergency contact REQUIRED
  
  Please fill out this field. Please enter a phone number.
- Allergies, medications, diet restrictions and physical limitations
- Health Insurance Provider REQUIRED Please fill out this field. Please enter valid data.
- Health Insurance Policy Number Please enter valid data.
- Primary Policy Holder Please enter valid data.
- T-shirt Size REQUIRED X-Small Small Medium Large X-Large XX-Large Please fill out this field.
- Comments, Questions
- I grant permission for me to participate in the event with St. Ambrose Catholic Church, Latham.
  
  I grant permission, if needed, to be evaluated, diagnosed, treated, and /or medicated in accordance with standard medical practice and by licensed medical personnel. I relieve St. Ambrose Church and the Roman Catholic Diocese of Albany of all responsibility and consequences that may arise as the result of this treatment.
  
  I will not hold the St. Ambrose Church and the Roman Catholic Diocese of Albany or any and all other participating chaperones responsible in the event of injury. Further, I agree to accept any and all financial responsibility as a result of scheduling such treatment.
  
  I agree to abide by all rules and regulations decided upon by theSt. Ambrose Church and the Roman Catholic Diocese of Albany. I understand that neither the Church of St. Ambrose nor the Roman Catholic Diocese of Albany will be held liable if I fail to cooperate with said regulations and that any infractions of the rules may result in immediate dismissal from the event. I further understand that I will be responsible for any costs or other requirements for immediate transportation home.
  
  Media/Photo Waiver: I hereby authorize and give my full consent to St. Ambrose Church and the Roman Catholic Diocese of Albany to copyright and/or publish any and all photographs, social media images and posts, video recordings and/or film in which I appear while participating in any programs sponsored or chaperoned by St. Ambrose and the Roman Catholic Diocese of Albany. I further agree that they may transfer, use or cause to be used, these photographs, videotapes, or films for any exhibitions, public displays, publications, commercials, art and advertising purposes and television programs without limitations or reservations.
- I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above terms. REQUIRED I agree Please fill out this field.
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