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Brave Chaperone Volunteer Form

- Faith Formation

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- Adult T-Shirt Size REQUIRED Please fill out this field.
- Do you require a vegetarian option? REQUIRED Please fill out this field.
- I do hereby release, hold harmless and discharge the Archdiocese of Galveston-Houston, the parish, its staff and volunteers from any and all liability, claim, loss, damage, cost or expense arising from my participation in this event. I waive such claims against such organization or any such person, arising directly or indirectly from or attributable in any legal way, to any action or omission to act of any such organization or person in connection with execution of this event. I authorize treatment by a licensed medical physician or licensed medical team in case of any accident or illness that may so arise, or any hospitalization necessary. do hereby release, hold harmless and discharge the Archdiocese of Galveston-Houston, the parish, its staff and volunteers from any and all liability, claim, loss, damage, cost or expense arising from my participation in this event. I waive such claims against such organization or any such person, arising directly or indirectly from or attributable in any legal way, to any action or omission to act of any such organization or person in connection with execution of this event. I authorize treatment by a licensed medical physician or licensed medical team in case of any accident or illness that may so arise, or any hospitalization necessary.
  I Agree Please select this field.
- I understand that promotional pictures and videos (individual and group) will be taken during this event. I give permission for my son's/daughter's picture to be used for promotional materials (newsletter, web page, calendars, power point, video, etc.) in highlighting the event.
  I Agree Please select this field.
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Street Address 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.
- Parish Please enter valid data.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Languages Spoken REQUIRED Please fill out this field. Please enter valid data.
- Physician's Name REQUIRED Please fill out this field. Please enter valid data.
- Physician's Phone Number REQUIRED Please fill out this field. Please enter valid data.
- (The following request is pertinent information if you're rendered unconscious.)
- Date of Birth (xx/xx/xxxx) REQUIRED Please fill out this field. Please enter valid data.
- Date of Last Tetanus shot(xx/xx/xxxx) REQUIRED Please fill out this field. Please enter valid data.
- Please list ALL medical conditions / allergies / special health information including bouts with depression and anxiety: REQUIRED Please fill out this field.
- Please list ANY medications (prescription or non-prescription) you would like us to be aware of: REQUIRED Please fill out this field.
- Name of Emergency Contact REQUIRED Please fill out this field. Please enter valid data.
- Phone Number of Emergency Contact REQUIRED Please fill out this field. Please enter valid data.
- Do you have Medical Insurance: REQUIRED Yes No Please fill out this field.
- If Yes, Please proivide the following information:
- Insurance Carrier Please enter valid data.
- Policy in the Name of: Please enter valid data.
- Policy Number Please enter valid data.
- Group Number Please enter valid data.
- In the event the participant does not have insurance, payment in full for medical care becomes the responsibility of the patient. REQUIRED I agree Please fill out this field.
- I agree to abide by any/all policies and rules established for this event/activity (see Code of Conduct). Should I not be able to maintain the guidelines and expectations of the adult chaperones/young adult assistants, I understand that there will be consequences for my actions, which could include being asked to leave the event.
- I Agree Please select this field.
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Brave Chaperone Volunteer Form

St. Bernadette Catholic Church
Archdiocese of Galveston-Houston

Office Hours

Brave Chaperone Volunteer Form

St. Bernadette Catholic Church Archdiocese of Galveston-Houston

Office Hours

St. Bernadette Catholic Church
Archdiocese of Galveston-Houston