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Encounter

Encounter Youth Registration
- Please complete this form to register your child for Encounter on September 21, 2024. Pricing is as follows:
  Regular Registration: $30 through Sept. 5
  Late Registration: $45 through Sept. 18 - T-shirts not guaranteed for late registrations
- The maximum number of form submissions has been reached. This form is currently not available.
  
  Participant First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Participant Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Gender REQUIRED Please fill out this field.
  
  T-Shirt Size REQUIRED Please fill out this field.
  
  Parent / Guardian Name REQUIRED Please fill out this field. Please enter valid data.
  
  Home Address REQUIRED Please fill out this field.
  
  Parent / Guardian Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  Parent / Guardian Email REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Name (other than parent listed above) REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Number REQUIRED Please fill out this field. Please enter valid data.
  
  Insurance Company REQUIRED Please fill out this field. Please enter valid data.
  
  Policy Number REQUIRED Please fill out this field. Please enter valid data.
  
  Current Medications & Dosage
  
  Allergies, medically prescribed diet, physical limitations, or other special medical conditions?
  
  I grant permission for my child to participate in this parish event that requires transportation to a location away from the parish site. This activity will take place under the guidance and direction of diocesan employees and/or volunteers from the Diocese of Lafayette-in-Indiana. As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“participant”).
  
  I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend the Diocese of Lafayette-in-Indiana, its employees and agents, chaperones, or representatives associated with the event, from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith. I agree to compensate the Diocese of Lafayette-in-Indiana, its employees and agents and chaperones, or representative associated with the event, for reasonable attorney’s fees and expenses which may incur any action brought against them as a result of such injury or damage unless such claim arises from the negligence of the parish/diocese.
  
  In the event of an emergency, I hereby give my permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact the listed Emergency Contact included above.
  
  I grant to the Diocese of Lafayette-in-Indiana the right, privilege and license to use the picture or likeness of my child in any photograph, movie, video production or any other forms of media publication and to use the verbal or written statements or declarations of my child for the purpose of publicizing, fostering and promoting the diocese and its programs, or for any other purpose in furtherance of the mission of the Diocese of Lafayette-in-Indiana.
  I Agree Please select this field.
  
  Encounter Registration45.0
  
  Donation REQUIRED Please fill out this field.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Total:
  
  Submit
  
  Proceed to Payment
  
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Muncie Catholic Pastorate

A PASTORATE OF THE DIOCESE OF
LAFAYETTE-IN-INDIANA

Encounter

Encounter Youth Registration