EDGE Laser Tag

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Youth Name*

First Name

Last Name

Age*

Grade *

Youth Name*

First Name

Last Name

Age*

Grade*

Youth Name*

First Name

Last Name

Age*

Grade*

Youth Name*

First Name

Last Name

Age*

Grade*

Parent Name*

First Name

Last Name

Parent Email*

Parent Phone*

If your E-mail is not on the Parish mailing list, would you like to add it? *

Yes No

Emergency Contact (other than parent listed above)*

First Name

Last Name

Emergency Contact Phone*

I request that St. Timothy permit me to attend the EDGE outing October 15, 2018 at Stratum Laser Tag in Mesa AZ. In consideration for my participation, on behalf of myself, my child(ren), and our heirs, assigns, executors and personal representatives, I hereby release, absolve, indemnify and agree to hold harmless St. Timothy Roman Catholic Parish Mesa, the Roman Catholic Church of the Diocese of Phoenix, and any and all of their officers, directors, agents, employees, representatives, volunteers, or sponsors from any and all liability for any and all injury that may arise out of participation in this activity, including any transportation or vehicle related incidents. I also authorize the supervisor of the EDGE event or his/her designee to seek/provide first aid or similar care in non-emergency situations, and to seek emergency medical assistance when they deem it necessary, for which I will be financially responsible. Further, I give permission to have photos taken of me for the purpose of parish use.

I/we agree*

Yes No

Please contact Meagan Martinez at (480) 775-5234.

Parent/Guardian Signature*

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Date/Time*

Total Due $