Servio Deo Rise Mission Trip 2025 | Chaperone Registration

Chaperone Information

Name

Gender

Female Male

T-shirt Size

Small Medium Large XL XXL XXXL

Cell phone number

Please enter the best email in the household to receive Mission Trip Info. To enter more than one, simply separate the addresses with a comma, for example - lifeteen@email.com, lifeteen@email.com

This address will receive a confirmation email

Enter all phone numbers you would like to receive text message reminders. For more than one, simply use a comma: 615.555.5555, 615.333.3333

Do you have any special skills that could be used on Mission Trip? Ex. construction, medical, cooking skills ...etc. If yes please tell us what you are experienced in.

How many seatbelts are in the car you could drive including the driver seat?

Please name make and model of vehicle if you have more than 8 seatbelts ( or other seat belt comments)

Anything else you think we should know.

Emergency Contact

Emergency Contact Name (an adult that is not listed above)

Emergency Contact Phone Number

Relationship to you

Health Information

Please check all that apply.

Medicinal Allergies Environmental Allergies Food Allergies Dietary Accommodations Medical Conditions Other Medical, Educational, or Psycological info that we would need to be aware of while on this trip None of these apply

If you checked anything above, please explain here.

List any medicinal, environmental, and food allergies as well as any dietary accommodations you will need.

Release and Waivers

Liability Waiver and Medical Release:
I give permission for myself to participate in this mission trip that requires transportation to a location away from the parish, school and Diocese. This activity will take place under the guidance and direction of parish employees and/or volunteers from St. Matthew Catholic Church. As parent and/or legal guardian, not St. Matthew Catholic Church, Diocese of Nashville, or those acting as chaperones, retain full legal, physical, and financial responsibility for my personal actions. I agree on behalf of myself, my heirs, assigns, executors, and personal representatives, to hold harmless and defend St. Matthew Catholic Church, Diocese of Nashville, its officers, directors, agents, employees, volunteers, or representatives associated with this mission trip from any and all liability claims, loss or damage arising from or in connection with my participation in this mission trip. In the event of an emergency, I give permission for any medical treatment deemed necessary by the Saint Matthew staff. I also permit them to transport me to any reasonably accessible hospital or physician’s office. I remain financially responsible for my medical treatment.

By typing my name here, I signify that I agree to the release/ medical waiver detailed above.

My name serving as digital signature

Today's Date

Media Waiver Release:

I give consent to be in photos and videos used to promote the Diocese of Nashville, Saint Matthew Catholic Church, and Catholic faith leaders. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me because of such use.

Media Release Options

I agree to the Media Release I do not give permission for my image to be used in the above mentioned manner.

By typing my name here, I signify that I agree to the media release detailed above.

My name serving as digital signature

Today's Date

Insurance Info

Name of Primary Card Holder for Insurance

Picture of Front of Insurance Card

Upload (8MB)

Picture of Back of Insurance Card

Upload (8MB)

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Servio Deo Rise Mission Trip 2025 | Chaperone Registration

Description

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