Fiat Registration - Diocese of San Jose

PARTICIPANT'S CONTACT INFORMATION

Participant's Name*

First Last

Email*

Phone (Cell preferred)

Address*

Street Address City State ZIP Code

Your Parish/School

ABOUT YOU

Date of Birth

Age on Date of Retreat*

What School Grade are you in?*

8th Jr. High
9th Freshman HS
10th Sophomore HS
11th Junior HS
12th Senior HS
Recent HS Graduate

Note: You must be an incoming 9th grader to outgoing senior to attend this retreat (unless otherwise arranged with the Fiat team)

What are your two favorite things to do with your friends?

2. Why do you want to attend the Fiat Retreat? (1-5 Sentences)

PARENT CONSENT AND CONTACT INFORMATION

Please complete the parent consent and contact informatio below.

Parent/Guardian 1 Relationship (ex. Mother, Father)

Parent/Guardian 1 Name

Parent/Guardian 1 Email

Parent/Guardian 1 Phone

Parent/Guardian 2 Relationship (ex. Mother, Father)

Parent/Guardian 2 Name

Parent/Guardian 2 Email

Parent/Guardian 2 Phone

Parent Consent

I the parent/guardian give consent and release for my child to participate at this event.

As a parent/guardian, type your name below as your electronic signature for your consent for your minor to participate.

QUESTIONS FOR RETREAT

How did you hear about this retreat?*

3. Other questions/comments (if any) (ex. questions about the retreat, etc.)

PHOTO/VIDEO RELEASE

Photo/Video Release Consent*

I give consent to the Photo/Video Release. I grant the Diocese of San Jose, its directors, officers, employees, agents, and designees (collectively “DSJ”) non-revocable permission to capture my/my child's image and likeness in photographs, videotapes, motion pictures, recordings, or any other media (collectively “Images”). I acknowledge that DSJ will own such Images and further grant the DSJ permission to copyright, display, publish, distribute, use, modify, print and reprint such Images in any manner whatsoever related to DSJ business, including without limitation, publications, advertisements, brochures, web site images, or other electronic displays and transmissions thereof. I further waive any right to inspect or approve the use of the Image by the DSJ prior to its use. I forever release and hold the DSJ harmless from any and all liability arising out of the use of the Images in any manner or media whatsoever, and waive any and all claims and causes of action relating to use of the Images, including without limitation, claims for invasion of privacy rights or publicity. No compensation to be given.

PARTICIPATION ACTVITIY WAIVER

Activity General Liability Waiver*

I have read and consent to the waiver as written below for this year's Fiat Retreat

TO THE EXTENT PERMITTED BY LAW, I HOLD THE PARISH/SCHOOL AND DIOCESE OF SAN JOSE HARMLESS FROM ANY CLAIM OF INJURY, SICKNESS, ILLNESS OR DAMAGE THAT I /MY CHILD MAY SUFFER OR SUSTAIN DURING THE ACTIVITY LISTED ABOVE, WITH EXCEPTION TO INJURY OF DAMAGES ARISING OUT OF THE SOLE NEGLIGENCE OF THE PARISH/SCHOOL OR DIOCESE OF SAN JOSE. I ATTEST THAT I AM/MY CHILD IS PHYSICALLY FIT TO PARTICIPATE IN THIS EVENT.

IN THE EVENT THAT I/MY CHILD BECOME(S) ILL OR INJURED, I DO HEREBY CONSENT TO WHATEVER MEDICAL TREATMENT(S), INCLUDING BUT NOT LIMITED TO X-RAY, EXAMINATION, OR HOSPITAL CARE, CONSIDERED NECESSARY IN THE BEST JUDGEMENT OF THE ATTENDING PHYSICIAN AND PERFORMED BY OR UNDER THE SUPERVISION OF A MEMBER OF THE MEDICAL STAFF OF THE HOSPITAL AND/OR OTHER MEDICAL FACILITY PROVIDING THE TREATMENT. I AM NOT AWARE OF ANY MEDICAL CONDITION WHICH WOULD RENDER IT INAPPROPRIATE FOR ME/MY CHILD TO PARTICIPATE IN ANY ACTIVITY ASSOCIATED WITH THIS EVENT.

I/my child hereby release and agree to hold PARISH/SCHOOL AND DIOCESE OF SAN JOSE harmless from, and waive on behalf of myself/my child, my heirs, and any personal representatives, any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself/my child and/or property that may be caused by any act, or failure to act of the PARISH/SCHOOL AND DIOCESE OF SAN JOSE, or that may otherwise arise in any way in connection with any Participant services I/my child provide(s) to the PARISH/SCHOOL AND DIOCESE OF SAN JOSE.

I/my child understand that this release discharges the PARISH/SCHOOL AND DIOCESE OF SAN JOSE from any liability or claim that I/my child, my heirs, or any personal representatives may have against the parish with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any Participant services provided to the PARISH/SCHOOL AND DIOCESE OF SAN JOSE.

This liability waiver and release extends to the PARISH/SCHOOL AND DIOCESE OF SAN JOSE together with its clergy, staff, and other Participants.

MEDICAL INFORMATION

Please provide participant's Medical Information below:

Medical Plan Name*

Medical Plan Address*

Medical Plan Policy Number*

Medical Plan Contact Phone Number*

EMERGENCY CONTACT INFORMATION

Emergency Contact(1) Name*

First Last

Emergency Contact(1) Phone*

Emergency Contact(2) Name*

First Last

Emergency Contact(2) Phone*

Type your name below as your electronic signature for your consent and participation activity waiver and photo/video release.*

Date of consent and waiver to the Fiat Retreat*

While this retreat is free, a suggested donation of $50 will be greatly appreciated to help us cover some of the retreat’s expenses. You can take with you to the retreat a closed envelope with your donation, or send a check as follows:
Pay to the Order of: Diocese of San Jose
Memo: Fiat 2026 Donation
Mail your check to:

Diocese of San José
Att. Vocations Office
1150 N. First St. Suite 100
San Jose, CA 95112

We Appreciate Your Generosity. See you at the Retreat!