TRANSFORMED Registration Form 2023

TRANSFORMED

Electronic Registration Form
Eucharistic Retreat AGES: 13 through YOUNG ADULTS

Location: Lander Community Center. 950 Buena Vista Dr. Lander, WY 82520

Contacts: Gerise 307.258.3221 or Elizabeth 307.554.6247

Date: February 17. 18, & 19,2023

Cost: 2/13/23 - $55 PP OR $65 PP 2/14/23 & AFTER

Attendees & Chaperones MUST PAY REGISTRATION FEE: $55.00 ($65 after deadline)
Please Fill Out a Form for Each Person Attending & Each Chaperone or parent Attending. One form per person. Thank you! We look forward to seeing you at the retreat!
PARTICIPANT/CHAPERONE INFORMATION
Name*
Address*
City/State/Zip*
Home Phone
Cell Phone*
Email*
example@example.com
Parish Name*
City*
Parish Leader or Chaperone Name*
Gender*
Birthdate *
Are There Dietary Restrictions? If so please explain below.*
I would like to pre-order a t-shirt to be picked up at the retreat. You may pick up & purchase t-shirts at the t-shirt table at the retreat.
PARENT GUARDIAN INFORMATION EMERGENCY CONTACT INFORMATION
(Father's Name)*
Father's Phone Number*
Please enter a valid phone number.
(Mother's Name)*
Mother's Phone Number*
Please enter a valid phone number.
Father's Email*
example@example.com
Mother's Email*
In many cases, our staff and volunteers are not familiar with the medical and/or physical history of each participant. Please share ANY information relating to the participant in detail. BE AS SPECIFIC AS POSSIBLE.
Is the participant allergic to anything?*
List any details of allergies (this may include food allergies)
Is the participant currently taking or has taken any prescription medication in the last 6 months? *
If yes, please list the specific prescriptions medication, reasons for medication, and daily dosage. Indicate if the medication is currently being administered.
Medical Information and Release Form All information is kept private and confidential.

RELEASE OF LIABILITY RELEASE OF CLAIMS AND MEDICAL RELEASE

The undersigned do hereby release, forever discharge and agree to hold harmless TRANSFORMED and its Organizers, participating parishes and their adult chaperones, and Lander Community Center from and against any and all liability, claims, demands, lawsuits and expenses of any kind arising from personal injury, sickness, death or property damage of any kind whatsoever which may be incurred or suffered by the undersigned and/or participant (if participant is under 18, 18 or older)

The undersigned further agree to indemnify and hold TRANSFORMED and its organizers, participating parishes and their adult chaperones, and Lander Community Center and its respective members, directors, employees, and agents (collectively, the "Indemnities,") harmless from and against any and all claims, demands, actions, lawsuits, and liabilities, including attorney fees and expenses and costs sustained by the Indemnities is a result of negligent, willful or intentional acts of the undersigned and/or participant (if participant is 18 or under, 18 or older if participant is under 18 years of age, (we) the parent(s) or legal guardian(s) of the participant, do hereby grant permission for your child to participate fully in the TRANSFORMED and all of its activities and hereby give permission to TRANSFORMED, participating parishes and their adult chaperones to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not limited to emergency surgery and / (we) fully and completely assume all responsibility for all medical bills.

Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, I (we) assume all responsibility and transportation costs.

This form MUST be signed by EACH participant including CHAPERONES. Fees must be paid by All (INCLUDING CHAPERONES If a participantis under 18, a parent or legal guardian must sign and participants must attend the Retreat with their own chaperone (one adult chaperone for every 1 to 7 young people in your youth group. NOTE: ANY PARTICIPANT UNDER 18 YEARS OF AGE MUST HAVE A WRITTEN PERMISSION SIGNED BY A PARENT OR LEGAL GUARDIAN TO LEAVE THE RETREAT DURING RETREAT HOURS. There must be one adult chaperone. age 21 and overfor every one to seven youth under the age of 18. Chaperones must arrive with, attend and stay with their youth during the Retreat in the same facility and room. All chaperones and volunteers must fulfill and be in compliance with their Diocesan policies and requirements for providing a safe and secure environment for minors. Chaperones are required to be present with their youth at all times, including talks, etc.
Name of Participant/Chaperone*
Participant/Chaperone (if over 18) or Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
I give permission for pictures and/or video of my child (named above) engaged in activities related to the retreat TRANSFORMED to have their pictures posted in the retreat TRANSFORMED publications or websites. Names of participants will not be used without expressed permission from the parent or guardian. If no box is checked below, TRANSFORMED assumes you give permission.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Select One *
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Early Bird TicketPlease select this option if you are purchasing on or before 2/13/2023
$55.00

Last Minute TicketPlease select this option if you are purchasing after 2/13/2023 (honor system in place)
$65.00

Total

$0.00

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

TRANSFORMED

Please Fill Out a Form for Each Person Attending & Each Chaperone or parent Attending. One form per person. Thank you! We look forward to seeing you at the retreat!

PARTICIPANT/CHAPERONE INFORMATION