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Encounter Chaperones

Encounter Chaperone Registration
- Please complete this form to register as a chaperone for Encounter on September 21, 2024. Pricing is as follows:
  Regular Registration: $15 through Sept. 5
  Late Registration: $25 through Sept. 18
  T-Shirts are not included with adult registrations. Adults may purchase a T-Shirt for an additional $15.
- The maximum number of form submissions has been reached. This form is currently not available.
  
  Chaperone First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Chaperone 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
  
  Home Address REQUIRED Please fill out this field.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  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.
  
  Allergies, medically prescribed diet, physical limitations, or other special medical conditions?
  
  I agree 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. I remain legally responsible for any personal actions taken by my own self.
  
  I agree on behalf of myself, 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 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 that I should require medical treatment and I am not able to communicate my desires to attending physicians or other medical personnel, I give permission for the necessary emergency treatment to be administered.
  
  I grant to the Diocese of Lafayette-in-Indiana the right, privilege and license to use my picture or likeness in any photograph, movie, video production or any other forms of media publication and to use my verbal or written statements or declarations 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 understand that all adults attending will need to have completed the diocesan Safe & Sacred training.
  I Agree Please select this field.
  
  Encounter Chaperone Registration15.0
  
  Donation
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Total:
  
  Submit
  
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Muncie Catholic Pastorate

A PASTORATE OF THE DIOCESE OF
LAFAYETTE-IN-INDIANA

Encounter Chaperones

Encounter Chaperone Registration