SouthEast

presents

When: April 15-17, 2011

Where: Sunny Acres Community Center
2850 Wompi Drive Jacksonville, FL 32225
Registration: $20.00 (to cover food, lodging and materials)

REGISTRATION FORM
Name: __________________________________________________________ Nick: ___________________

Address: ________________________________________________________________________________

City: ______________________________________ State: _____ Zip: ____________

Phone: ____________________________________ DOB: __________|________|________

Email: __________________________________________________________________________________

Emergency Contact (phone # & relationship): ________________________________________________

Dietary/health restrictions: __________________________________________________________________

PARENT CONSENT & WAIVER FORM

For ages 18 or below, please have parent/s or guardian complete below

I (We), the undersigned parent(s) and/or guardian(s) of the participant whose name appears above, hereby
give(s) my (our) consent for the participant to attend SHOUT, which will be held at Sunny Acres Community
Center on April 15-17, 2011.

I (We) understand and assume the risk inherent with this event from other parties, but I (we) also understand
that all reasonable care and supervision will be exercised to provide for the general well-being of the
participant. I (We), individually and on behalf of the participant, do hereby release, covenant not to sue, and
save harmless, Couples for Christ, CFC Youth USA, Diocese of St. Augustine, its officers, staffs, and
volunteers from any and all claims, liability, costs, damage to any property caused by or arising out of my (our)
child’s participation in the event.

Parent/Guardian’s/ Participants Signature: ________________________________________________

Parent/Guardian’s/ Participants Name: ___________________________________________________