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  • YOUTH REGISTRATION, MEDICAL RELEASE AND PERMISSION COMBINED FORM
    Event Name: Souper Bowl of Caring 2021
    Event Date: Sunday February 7, 2021 1:30-3:00pm
    Event Location: Martha's Kitchen 139 Lake St St Albans

    
    Student Information:
     
  • First Name REQUIRED Please fill out this field. Please enter valid data.

    Last Name REQUIRED Please fill out this field. Please enter valid data.
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    State REQUIRED AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY Please fill out this field.

    Zip REQUIRED Please fill out this field. Please enter a zip code.
  • Parent or Legal Guardian Information:
  • First Name REQUIRED Please fill out this field. Please enter valid data.

    Last Name REQUIRED Please fill out this field. Please enter valid data.
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    Last Name Please enter valid data.
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  • Email REQUIRED Please fill out this field. Please enter an email address.
  • II. Parental Agreement
    I, the parent/guardian of the above listed child(ren) who is less than nineteen years of age, grant permission for my daughter/son to participate in the Souper Bowl of Caring Soup Day of Service at Martha's Kitchen By allowing my child to participate in the said program, I hereby assume all risk of accident or harm arising or growing out of, directly or indirectly, any incident of any kind occurring during the course of such program to my child and do hereby release and discharge the Diocese of Burlington, and _Nativity BVM-St. Louis parish trust/school, and the agents, associates, and employees of the Diocese of Burlington and parish trust/school, Martha’s Kitchen and all who have organized or participated in the supervision of such program from all claims, demands, suits, causes or actions, rights, costs, expenses, and any compensations whatsoever which may occur to my family and its members during or resulting from participating in the program mentioned.
    
    I am aware of the particulars of the said program including the times, costs, and adults chaperoning and/or transporting my child for the program and have clarified any concerns I may have with the coordinating adult in charge. I agree to transport my child to and from this event or arrange for the safe transportation of my child. I agree that my son/daughter shall abide by the rules and all regulations of the program including in regards alcoholic beverages, drugs, and weapons. I agree that if my son/daughter fails to abide by the regulations set forth, he/she may be dismissed from the program and I will need to arrange for his/her immediate transportation home at my expense.
    
    I understand that photographs or video taken at this event may be used in parish trust or diocesan publications, or Martha's Kitchen publications.

     

    
    
     
  • I Agree Please select this field.

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