HSFF Degage Ministries

Name of Event: Degage Ministries- Bingo with Chips and Salsa
Location: Home of the Achatz Family: 144 Division Ave S, Grand Rapids, MI 49503
Supervisor of Activity: Nickie Wentworth-Holton 616-318-0055
Date, Time, & Drop Off: Saturday, January 27, 2018, 9:30 AM
Date, Time, & Pick Up: Saturday, January 27, 2018, 11:00 AM
Method of Transportation: Own
Cost: FREE

Student Name:
Will others in your family be joining for this event? If so, please list name and age below.

Address: , , MI,
Allergies, Restrictions or Recommendations


Parent/Guardian Name:
Parent Phone: or
Parent Email:
I certify that I am the of the minor child named above and I agree to the above terms for myself and for my minor child.

Emergency Contact other than parent:
Emergency Contact will only be contacted if parent is not available

Family Physician:

Health Insurance Data
**If your policy does not have some of these areas of information, please enter NONE**
Policy Number:
Group Number:
Contract Number:

Consent for Participation:
I hereby consent to participation by my child in the event described above. I understand that this event will take place off parish grounds. I further consent to the conditions stated above on participation in this event, including the method of transportation.

In consideration of my child being allowed to participate in this event, I agree to waive and release, and indemnify and hold harmless Our Lady of Consolation Parish, any and all affiliated organizations, its/their employees, agents, representatives, volunteers and drivers, from any and all claims I or my child may have, excluding claims for intentional misconduct or gross negligence, arising from or relating to my child’s participation in this event.

Consent for Medical Treatment:
As a parent/guardian, I do hereby authorize first aid/medical treatment of my child in the event of an emergency which may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed. It is understood that efforts will be made to reach me as soon as reasonably possible.

Consent for Photo & Media Consent:
As legal guardian of the aforementioned child to participate in the Our Lady of Consolation Parish Formation Programming. I understand that photography and/or video of participants may be procured during Formation Programming and used in promotional materials. I consent to the use of images and likenesses of the aforementioned person, for promotion purposes by Our Lady of Consolation Parish, including the Our Lady of Consolation Parish website and Facebook page.