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NET Retreat | January 28, 2024 | 2p-8p

- Registration Deadline: January 21
  
  The maximum number of form submissions has been reached. This form is currently not available.
  
  Parent
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Emergency Contact (other than parent)
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Number of Teens Registering REQUIRED Please fill out this field.
  
  Teen 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Birthdate REQUIRED Please fill out this field. Please enter a date.
  
  Grade Level REQUIRED Please fill out this field.
  
  Please list any dietary restrictions. Please enter valid data.
  
  Teen 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Birthdate REQUIRED Please fill out this field. Please enter a date.
  
  Grade Level REQUIRED Please fill out this field.
  
  Please list any dietary restrictions. Please enter valid data.
  
  Teen 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Birthdate REQUIRED Please fill out this field. Please enter a date.
  
  Grade Level REQUIRED Please fill out this field.
  
  Please list any dietary restrictions. Please enter valid data.
  
  Teen 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Birthdate REQUIRED Please fill out this field. Please enter a date.
  
  Grade Level REQUIRED Please fill out this field.
  
  Please list any dietary restrictions. Please enter valid data.
  
  MEDIA RELEASE
  
  On occasion, St. Alphonsus Liguori Catholic Church takes photographs or makes an audio or video recording of children and/or adults involved in parish activities. Images may be used on parish print, electronic, and social media platforms.
  
  I expressly grant to St. Alphonsus Liguori Catholic Church the right, privilege and license to use the picture or likeness of my child/children 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/children for the purpose of publicizing, fostering and promoting the parish and its programs.
  
  Please answer according to the publicity statement above: REQUIRED Yes No Please fill out this field.
  
  LIABILITY RELEASE
  
  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 officers, directors, 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, and I agree to compensate the Diocese of Lafayette-in-Indiana, its officers, directors, its employees and agents, chaperones, or representatives associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the Diocese of Lafayette-in-Indiana.
  
  Please answer according to the liability statement above: REQUIRED Yes No Please fill out this field.
  
  Registration Form Consent - Parent/Guardian First and Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  Finances should never be the reason a teen does not attend an event. If you need financial assistance, please email [email protected].
  
  Registration Fee30.0
  
  Fee Discount30.0
  
  Number of Teens Registering REQUIRED One Teen Two Teens Three or More Teens Please fill out this field.
  
  Total:
  
  Submit
  
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