LSSL Program Opportunity - December 1st/2nd

Lloyd Sippel Servant Leadership Opportunity

All students (and families!) are invited to join us for our upcoming service opportunity at Arbor View Assisted Living (34201 Arbor Lane, Burlington, WI 53105) for Christmas decorating, caroling, and pizza dinner with residents from 3:30-7:30 PM. Please complete the form below to reserve your spot! Questions? Contact Nic Kelly at nickelly@cchsnet.org
Student's Name*

First NameLast Name
Grade
Parent/Guardian Name*

First NameLast Name
Primary Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Email*
example@example.com
Will you be attending/participating at this event?*
Will any family members be joining you for this service opportunity? If yes, please list their names and relationship to you.*
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Relationship to Student*
Pertinent Medical Conditions:
Medical Information and Release
In the event of an emergency, I give permission to transport my child to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. On field trips that occur during the length of the school day, any prescription medication already provided to the school will be carried and administered by staff.
I agree to the above terms.*

Yes
Parent Volunteers
Catholic Central welcomes parent support at service events. If you are interested in chaperoning for future opportunities, please note that all volunteers must be Safe Environment certified through the Archdiocese of Milwaukee before participating.*

Yes, I am Safe Environment certified and would like to volunteer as a chaperone.I am interested in volunteering for future events and will begin the Safe Environment certification process.Not at this time.
Some service opportunities may take place off campus, requiring transportation to and from the event. When possible, Catholic Central will provide bus transportation. If a bus is not available, families may be asked to provide transportation for their student or assist with carpooling. (Important note: All parents who drive students, other than their own, must be Approved Driver certified through the Archdiocese of Milwaukee and meet all Safe Environment requirements including background check and driver verification prior to transporting any student.)*

Yes, I am interested in helping carpool other students.No, I am not interested in helping carpool other students.
Consent and Release
In consideration for my child/ward’s participation, I agree to reimburse and indemnify the parish/school for all reasonable legal and court fees incurred by parish/school in defending a lawsuit that I or my child/ward may bring against the parish/school Which relates to the above named activity if the parish/school is found not legally liable by the courts and prevails in the lawsuit. If the parish/school is found legally liable for injuries sustained by child/ward, this paragraph will not apply.
I agree to the above terms.*

Yes
I certify that I have an understanding of this agreement and any risks and hazards associated with the activity described above that my child/ward will be participating in. I further understand that I had the opportunity to fully discuss this agreement with a representative of the parish/school to clarify any concerns or questions about the activity or this agreement that I may have had.
I agree to the above terms.*

Yes
Check the box if you opt out of any image, photograph, or video of you child to be posted or published to social media by any chaperone or school personnel for this event.*

YesNo
Parent Signature *

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Student Signature*

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Lloyd Sippel Servant Leadership Opportunity

Medical Information and Release

Parent Volunteers

Consent and Release