Appalachia Adult Registration Form

If you will be 18 years old by July 7, 2020, please fill out the this registration form. If you are younger, please fill out the Teen Registration Form.

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Gender REQUIRED Male Female Please fill out this field.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

Address REQUIRED Please fill out this field. Please enter valid data.

Address 2 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.

Occupation Please enter valid data.

T-shirt Size (adult unisex) S M L XL XXL XXXL

Are you a member of St. Thomas More/St. John Capistran Parish?

How many times have you attended the Appalachia Mission Trip with STM? Please enter valid data.

Have you ever worked with youth before? If so, in what capacity?

List any skills or talents you are willing to share:

Are you interested in assisting with daily Mass? No Eucharistic Minister Lector Altar Server Coordinator

Are you interested in assisting with music? If so, which instrument? Please enter valid data.

Are you interested in assisting with faith-based evening programs? Yes No

Are you interested in assisting with the planning of recreational events? Yes No

Are you attending full-time or part-time? If part-time, please list the dates.

Are you planning to drive your own vehicle? Yes No

If you are driving your own vehicle, is anyone riding with you? Please enter valid data.

Will you drive to and from West Virginia with the rest of our caravan? If not, please explain:

Are you at least 25 years old and able, experienced, and willing to drive a 12-passenger van? Yes No

Agreements REQUIRED I understand that I am required to comply with all Diocesan Safe Environment Policies. I understand the cost per person of this trip is $400. To secure my spot I will submit $100/individual ($200/family) to Karen (made out to STM) by 10/31/19. I understand that I must fund raise or pay the remaining balance by 6/5/20. I understand that this trip is a Youth Ministry Program, and that in choosing to be part of it, I agree to chaperone, lead, instruct, and encourage the teens in our St. Thomas More group. Please fill out this field.

Photo Release: The Appalachia Mission Trip has my permission to use my/my child's photograph publicly to promote the Appalachia Mission Trip. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.

Agree

Liability Release: In consideration for being accepted by St. Thomas More for participation in this event, I do hereby release, forever discharge and agree to hold harmless St. Thomas More Roman Catholic Church and the Diocese of Pittsburgh, thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by myself while participating in the above described event. Furthermore, I hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to St. Thomas More to furnish any necessary transportation, food and lodging for me. I further hereby agree to hold harmless and indemnify St. Thomas More, and its employees and agents, for any liability sustained as the result of the negligent, willful or intentional acts of myself, including expenses incurred attendant there to.

Agree

Health Insurance Company REQUIRED Please fill out this field. Please enter valid data.

Policy Number REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact Name REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact Phone Number REQUIRED Please fill out this field. Please enter valid data.

Any known allergies?

Any physical limitations or work restrictions?

Any medically prescribed dietary needs?

Signature REQUIRED Please fill out this field. Please enter valid data.

I hereby declare these statements to be true and factual. I assume responsibility for my answers and understand all material herein.

Today's Date REQUIRED Please fill out this field. Please enter valid data.

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Appalachia Adult Registration Form

Appalachia Adult Registration