Event Details

Title: Spring Swing Dance

Location: St. Charles in Pittsfield

Date: April 27th

Lesson: 6-6:30pm

Dance: 6:30-9pm

Transportation: Transportation to event must be provided by parent or group leader

Event Sponsor: The Office of Youth Ministry / The Parishes of Berkshire County

Contact: Mary Makuc at [email protected] or 413-440-9381

Audience: Open to Middle through High School students

Cost: $5

All group leaders, adult volunteers, and parents who would like to attend the event must pass a CORI background check and attend a VIRTUS training in addition to signing the diocesan Code of Conduct, pursuant to Diocesan Safe Environment policies as outlined here: https://diospringfield.org/Ministries/child-youth-protection/

In order to access tickets, parents must sign the waiver at the end.

Child(ren) Information

Name*

Grade*

Gender*

Male
Female

Please list any food allergies.

Medications and Dosage (as applicable)

Please select all that apply. (Optional)

I hereby grant permission for nonprescription medication (such as acetaminophen, decongestant, cough syrup) to be given to my child(ren), if requested by my child(ren) and deemed advisable by an adult chaperone.
Other than the medication(s) listed above, no medication of any type whether prescription or nonprescription may be administered to my child(ren) unless the situation is life threatening and emergency treatment is required.

Please select all that apply. (Optional)

Mobility Impaired
Wheelchair Access
Hearing Impaired/Interpretation Needed
Visually Impaired (more than wearing glasses)
None of the above

Please list any additional medical information and recommended course of action (allergies, dietary restrictions, physical handicap or illness that would prevent him/her from participating in unusual vigorous activity, special conditions, learning modifications, etc.)

Registration Options*

Pay Now (Credit Card) ($5.00)
Pay Later (Cash Day of) ($0.00)

Parent Information

Youth Group or Parish

Parent Name*

Parent Email*

I consent to further communication about the event from the Office of Youth Ministry.

Parent Phone Number*

Yes, it's okay to send me text messages including confirmations, changes, and updates. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

Would you be interested in more information about the Diocesan Youth Leadership Team: Berkshires Chapter?

Parent/Guardian Release, Hold Harmless/ Indemnify Agreement*

By digitally signing this waiver, I the parent/guardian of the mentioned child(ren), who is/are less than 19 years of age, agree with the above terms and grant permission for my child(ren) to participate in the above-named Event. I understand that there is the potential risk of serious injuries to my child(ren) from participating in this Event. By allowing my child(ren) to participate in this Event, and in consideration for his/her being allowed to participate by the above named Parish/School/Cemetery, I hereby assume on behalf of my child(ren) all risk of accident or harm to my child(ren) arising out of, directly or indirectly, any incident of any kind occurring during the course of, including travel to and from, this Event, and do hereby release and discharge the Roman Catholic Bishop of Springfield, A Corporation Sole, the above named Parish/School/Cemetery, and their officers, directors, agents, employees, administrators, representatives, grantees and assigns (collectively referred to as “Releasees”), of and from all debts, demands, actions, causes of action, suits, accounts, covenants, contracts, agreements, costs, fees, expenses, losses, damages and any and all claims and liabilities whatsoever of every name and nature, both in law and in equity, whether known or unknown, that I or my child(ren) have ever had, now have, or may hereafter have, against the Releasees relating to or arising out of this Event. I further agree on behalf of my child(ren) to protect, defend, hold harmless, and fully indemnify the Releasees for any claim or cause of action whatsoever relating to or arising out of the participation of my child(ren) in this Event that may be brought against the Releasees, or any one of them, by any person, or entity, including without limitation, my child(ren) or his/her family members. I agree that my child(ren) shall abide by the rules and all regulations of the Event including in regards to alcoholic beverages, drugs, and weapons. I agree that if my child(ren) fails to abide by the rules and regulations set forth, he/she may be dismissed from the Event and I will need to arrange for his/her immediate transportation home at my expense. I understand that photographs or video may be taken at this Event showing images of my child(ren) and may be used in Parish, Cemetery or Diocesan publications, and I consent thereto.

I, the undersigned, agree to the terms above.

Emergency Contact

In the event of an emergency, I hereby grant permission to transport my child(ren) and obtain emergency medical or surgical treatment(s) from a licensed physician, hospital, or medical clinic. I hereby authorize medical personnel to release necessary information about his/her care to the parish or school group leaders(s) named above. I wish to be advised in the event of an emergency and prior to further treatment by the medical provider. In the event that I cannot be reached, please contact the below person.

Emergency Contact Name*

Phone Number*

Emergency Contact Relationship to Child(ren)*

I certify that my child/children is/are physically fit and adequately prepared to participate in this Event.*

Family Physician Name and Phone Number

Running Total

$5.00

Coupon Code

Total

$5.00

Your current total for 1 is $6.25 (Show Summary)

Billing Information

Name*

Credit Card*

Visa
Mastercard
American Express
Discover

Address*

Email*

Mobile Phone Number*

Yes, it's okay to send me text messages including confirmations, changes, and updates. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.