Night Maze at Bob's Corn - September 30th

To find out more about Bob's Corn Maze & Pumpkin Farm, please go to: https://bobscorn.com/corn-maze/

Please fill out this form for each participant. Thank you!

Participant Information

All fields required unless otherwise noted.

First & Last Name

Date of Birth

Grade

Needs/Consideration

Please make note of any dietary needs, health considerations, or other needs that the participant has, so that we can have the most successful trip possible! - Thank you!

Dietary Needs

Nut free Gluten free Dairy free Lactose free None

Type other dietary needs here

Health Considerations

Has an Epi-Pen History of seizure Prone to fainting Other- Note below None

Allergies or health needs
Please make not of any other medical conditions, allergies, sensitivities, or needs that the participant has that would be beneficial for us to know.

Type your Answer

Is participant subject to homesickness, emotional reactions to new situations, fainting, anxiety, etc. ?

Yes/No

Explained:

Physical Limitations (write n/a if not applicable)

Month/year of last Tetanus/Diphtheria immunization

Has the Child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc.:

Select one:

If Yes: date and disease/condition exposed to.

Chronic or other medical conditions:

You may administer 'over the counter' (OTC) medications to my child upon request such as: ibuprofen, throat lozenges, tums, seasonal allergy pills, Benadryl, ETC.

Parent/Family Information.
Please include your email as you will receive a confirmation after submitting the form.

Parent/Guardian name (1) - First & Last

Phone

This address will receive a confirmation email

Address

Parent/Guardian name (2) - If not applicable, write "NA".

Phone

Address

Parents: If you would like to help out with this trip, we are in need of transportation to the farm and back.

Please indicate below if you can provide transportation there or back to MQP.

Fill out the transportation form and turn it into Maria Musgrave Acosta, MS Youth Minister or Anne Sweeney, HS Youth Minister

https://archseattle.org/wp-content/uploads/2020/11/DriverFormRev12.2016.pdf

Indicate below if you prefer to drive your son/daughter there and back and opt-out of the carpool.

Transportation

Carpool TO Maze Carpool FROM Maze Meet AT MAZE

IN CASE OF EMERGENCY

If the above parent(s)/legal guardian(s) CANNOT BE REACHED, the emergency contact(s) below will be contacted.

At least 1 of your emergency contacts must be someone other than a parent/legal guardian.

In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any futher treatment by the hospital or doctor.

In the event of an emergency, if you are unable to reach me at the above numbers, contact:

Emergency contact name (First & Last)

Phone number

Relationship

Emergency contact #2 (optional)

Phone number

Relationship

Medical Information - Write "NA" if not applicable
All Information will be kept confidential and will only be used if needed.

I Hearby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.

Check here

Participant Insurance Provider

Policy/Group number

Family Doctor Name

Doctor Phone

PARENTAL PERMISSION:

I, the parent or legal guardian of the child named on this form, give my permission for the above named child to participate in this event that may require transportation away from the parish site. This event will take place under the guidance and direction of parish employees and/or volunteers from Mary Queen of Peace Sammamish and Holy Family Kirkland on 3/31/23 - 4/2/23.

As a parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor ("participant"). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns to hold harmless and defend Holy Family Kirkland, its officers, directors, employees and agents and the Archdiocese of Seattle, its employees and agents, chaperones or representatives associated with this event, and I agree to compensate the parish, its officers, directors and agents and the Archdiocese of Seattle from any claim arising from or in connection with my child attending the event or in association with any illness or injury (including death) or cost of medical treatment in connection there within, and I agree to compensate the parish, its officers, directors and agents and the Archdiocese of Seattle, its employees and agents, chaperones or representatives associated with this event for reasonable attorney's fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/diocese.

Please type your full name below to acknowledge.

Please type full name here.

PHOTOGRAPHY/VIDEOGRAPHY RELEASE:

From time to time, pictures and video may be taken of events and gatherings. We would like to be able to use these photographs and videos for flyers, parish and diocesan publications, and the ministry website. If there are concerns about pictures or videos posted on the website, please contact the Youth Minister at youth@mqp.org and they will be promptly removed.

I/we, the parent(s)/guardian(s) of this youth authorize and give full consent, without limitation or reservation, to Mary, Queen of Peace (Sammamish, WA) to publish any photograph or video in which the above named student appears while participating in the Night Maze at Bob's Corn event. There will be no compensation for use of any photograph or video at the time of publication or in the future.

Photography/Videography Release granted?

Yes No

Please type out your full name to acknowledge.

Payment Information

$15 Entrance Fee (discounted MQP Youth Ministry rate - Bob's admission is $22 without this discount)

Scholarships are available! Check the box below for a scholarship. Please consider donating any amount that you are able to contribute.

Please send $10-$15 cash with your child for them to purchase food at the event.

Payment

Disclaimer
By submitting this form you are consenting that everything above is true to the best of your knowledge and/or you consent to the disclosed permissions.

I am excited to share this opportunity for fellowship with your son/daughter!

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Night Maze at Bob's Corn - September 30th

Description

Please Fix the Following