Welcome to the Diocese of Bridgeport's
Fan the Fire Youth Rally registration!
begin
 
I am a... *


 
I want to... *


 
Group Leader Name: *

 
Group Leader Date of Birth: *

 
Group Leader Street Address: *

 
City, State, Zip Code: *

 
Group Leader Cell Phone: *

 
Adult Name: *

 
Adult Date of Birth: *

 
Adult Street Address: *

 
City, State, Zip Code: *

 
Adult Cell Phone: *

 
Youth Name: *

 
Youth Date of Birth: *

 
Youth Street Address: *

 
City, State, Zip Code: *

 
Parent or Guardian Name: *

 
Parent or Guardian Cell Phone: *

 
T-Shirt size: *


 
Allergies or medical conditions: *

 
Medical Insurance Provider: *

 
Emergency Contact Name: *

 
Emergency Contact Phone: *

 
Total # of Youths (under 18 years old): *

 
Total # of Youths (over 18 years old): *

 
Total # of Adults: *

 
Total Participants: *

Including yourself
 
T-Shirt sizes:

 
Small: *

 
Medium: *

 
Large: *

 
Extra Large: *

 
PERMISSION & MEDICAL CONSENT – ADULT PARTICIPANT

I am attending the Fan the Fire Youth Rally to be held on Saturday, August 19th, 2017 at St. Joseph High School in Trumbull, CT. If needed for health reasons, I give permission for myself to be evaluated, diagnosed, treated and/or given medication in accordance with standard medical practice by licensed medical personnel. I relieve St. Joseph High School, the Diocese of Bridgeport and Catholic Youth Ministry Group of all responsibility and consequences that may arise as a result of this treatment. I will not hold St. Joseph High School, the Diocese of Bridgeport and Catholic Youth Ministry Group liable in the event of injury. Further, I agree to accept any and all financial responsibility as a result of scheduling medical treatment. 

I agree to abide by all rules and regulations stated by all St. Joseph High School, the Diocese of Bridgeport and Catholic Youth Ministry Group and the Fan the Fire Youth Rally staff. I understand that any St. Joseph High School, the Diocese of Bridgeport or the Catholic Youth Ministry Group will not be held liable if I fail to cooperate with regulations, and that any infraction of the rules may result in immediate dismissal from the youth rally at my expense. 

I give permission to any St. Joseph High School, the Diocese of Bridgeport and Catholic Youth Ministry Group to photograph, videotape and/or film myself and to use my image in photographs, video, and/or film for the purpose of promoting the mission, activities, and programs of the Fan the Fire Youth Rally. I understand that I am are not entitled to any compensation or rights in these materials, and I release all St. Joseph High School, the Diocese of Bridgeport and Catholic Youth Ministry Group from any liability for the use of my image for the above stated purposes. *


 
You must agree to the terms and conditions to submit registration.

 
Please confirm you agree to these terms and conditions by entering your name as you entered earlier ("{{answer_47781027}}"): *

 
Please confirm you agree to these terms and conditions by entering your name as you entered earlier ("{{answer_47778523}}"): *

 
Parent/Guardian Medical Consent

The undersigned do hereby request and consent that my child attend and participate in Fan the Fire Youth Rally to be held on August 19th, 2017 at St. Joseph High School in Trumbull, CT. I authorize an adult, in whose care the minor has been entrusted, to render supervision and to provide consent to any X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician, dentist or emergency medical technician licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or treatment center whether such diagnosis or treatment is rendered at the office of said physician or said hospital or treatment center.

 The undersigned shall be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this request and authorization. The undersigned does also hereby give permission for my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in the above activity sponsored by the Diocese of Bridgeport.

I give permission to all St. Joseph High School, the Diocese of Bridgeport and Catholic Youth Ministry Group to photograph, videotape and/or film my child and to use his or her image in photographs, video, and/or film for the purpose of promoting the mission, activities, and programs of the Fan the Fire Youth Rally. I understand that I and my child are not entitled to any compensation or rights in these materials, and I release all St. Joseph High School, the Diocese of Bridgeport and Catholic Youth Ministry Group from any liability for the use of my child’s image for the above stated purposes.
*


 
You must agree to the terms and conditions to submit registration.

 
PARENT /GUARDIAN REQUEST AND RELEASE OF ALL CLAIMS

In consideration for being accepted by St. Joseph High School and the Diocese of Bridgeport for attendance at and participation in the above-listed activity and associated activities, on behalf of my child participant (if under the age of 21), I do hereby assume all risk of personal injury, sickness, death, damage, expense as a result of participation in all activities involved therein.

 The undersigned further hereby agree to hold harmless, and indemnify said parish, its directors, employees, agents and adult volunteers, for any liability sustained as a result of the negligent, willful, or intentional acts of said participant, including expenses incurred attendant thereto. I, thereby request participation and grant permission for above mentioned child to participate fully in said activity, and hereby give my permission to accompanying chaperones to supervise, care, and discipline my child.

 Further, should it be necessary for the participant to return home due to medical reason, disciplinary action or otherwise, I assume all transportation costs. When travel to, and from the activity is not parish sponsored, I assume all liabilities for any personal injury, damage and expense incurred as a result of riding in or driving any vehicle to and from said activity.

I have read and agree to the itinerary attachments, if applicable, standards of conduct and honor code of the Diocese of Bridgeport. *

     
 
You must read and agree to the itinerary attachments to submit registration.

 
Please confirm you agree to these terms and conditions by entering your name as you entered earlier ("{{answer_47781801}}"): *

 
The cost for Fan the Fire is {{var_price}}.
Would you like to pay online now with a credit card, or later by cash or check? *

If paying by cash or check, instructions will be provided before submitting.

 
Paying by cash or check

Please submit payment of $40 to your parish or school leader.

Parish or school leaders will gather those payments and submit them on the day of the event. *


 
The cost for Fan the Fire is $40 per participant.

Please bring final payment as cash or check on the day of the event.

That's all! Press continue and submit to complete registration.

 
You have chosen to pay by credit card. Please proceed below.

 
Please enter your Credit or Debit Card number:

 
The CVC number:

(3 or 4 digit security number on the back of your card)
 
The name on your card:

 
Your card's expiry month:


 
Your card's expiry year:


Thank you! Your registration for Fan the Fire has been submitted.

Please check your email for confirmation.
Fan the Fire
Thank you! Your registration for Fan the Fire has been submitted.

Please check your email for confirmation.
Fan the Fire