2024 Shadow Day Registration

Preferred Shadow Date*

Please select your second choice in case your preferred date is full.

How did you hear about Chesterton Academy of The Florida Martyrs?*

Name*

First NameLast Name

Age*

Sex*

MaleFemale

Current Grade*

Priority will be given to current 8th grade students.

Current School*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Contact Parent or Guardian*

First NameLast Name

Email Address*

example@example.com

Phone Number*

Please enter a valid phone number.

Additional Parent or Guardian

First NameLast Name

example@example.com

Phone Number

Please enter a valid phone number.

First NameLast Name

Phone Number*

Please enter a valid phone number.

May we include photos and/or video of your student in our school's social media and marketing materials?

YesNo

If you would like your student to participate in our school's shadow day, please sign the following statement of consent and release of liability. As parent or legal guardian, you remain fully responsible for any legal responsibility which may result from any personal actions taken by your youth.

But allowing our student to participate in a shadow day at Chesterton Academy of The Florida Martyrs, we assume all risks and hazards incidental to such participation and do hereby release, absolve, indemnify and agree to hold harmless the Diocese of Pensacola-Tallahassee, Chesterton Academy of The Florida Martyrs, and St. Anne Parish, and their employees, agents, volunteers, and other persons acting on their behalf. Neither the Diocese of Pensacola-Tallahassee, Chesterton Academy of The Florida Martyrs, St. Anne Parish, nor said agents, employees, or volunteers, shall be held financially responsible for any injury, illness or other loss incurred as a direct or indirect result of this activity. We the undersigned have read this release and understand all its terms and execute it voluntarily and with full knowledge of its significance.

EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I/we hereby authorize the Diocese of Pensacola-Tallahassee, Chesterton Academy of The Florida Martyrs, and St. Anne Parish, through their authorized representatives, to transport my child to a hospital or other doctor’s office or medical facility for emergency medical attention. I/We additionally authorize such representatives of the Diocese and/or School to obtain and give consent to whatever medical treatment the representative deems necessary, including the administering of anesthetic and surgery, and do hereby release the Diocese, Chesterton Academy of The Florida Martyrs, and St. Anne Parish, and their authorized representatives from any and all claims which may arise from the above-referenced obtaining and consenting to medical treatment. I/We wish to be advised, if possible, prior to the providing of any non-emergency medical treatment by any physician or hospital.

Signature

2024 Shadow Day Registration

Preferred Shadow Date

Student Information

Parent Information

Emergency Contact

Permission and Release of Liability