Welcome to St. John Vianney Catholic Family Life Center. We hope you grow in grace, strength and friendship.

Adult Registration Form

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PARTICIPANT INFORMATION /MEDICAL EMERGENCY FORM

Participant’s Name Nick Name

Address

City__________________________________________ State____________Zip Code________

Home Phone ___________________________work # _________________________________

E-Mail Address_________________________________________Cell Phone #

Home Parish Date of birth_____________________

Catholic ( ) Non-Catholic ( ) Male ( ) Female ( )

Emergency Contact Person Phone

If any on-going medical problems please indicate: _____

If you are currently taking any form of medication, please indicate type of

Medication/frequency: _______________________________________________________

_____________________________________________________________________________

Assumption of Risk

By executing this registration form the named participant represents and warrants that they are unaware of any physical or mental impediment that would or could cause injury or harm to the participant or to others by the said participant’s participation in the activities of the St. John Vianney Family Life Center. Due to the strenuous nature of some activities, the participant is urged to consult a physician concerning their fitness to engage in activities prior to executing this registration. Since all activities present certain inherent and/or inadvertent risks and hazards, know and acknowledge by the undersigned, by their execution hereof, assume all liability incident to the said participation, except that liability, which is imposed by law on the Catholic Archdiocese of Washington, their employees, agents or volunteers.

Signature_______________________________________________ Date ________________

You will NOT be allowed to participate in any activities unless this form is PROPERLY completed and signed.