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High School Winter Lock-In

- Faith Formation

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- Event Details
  Date of Event: Friday January 10th 9:00pm - Saturday January 11th 6:00am
  Description: Christmas Festivities, Food, Fun!
  Destination: 13505 Excelsior Blvd
  Minnetonka, MN 55345
  Time Frame: 9pm - 6am
  Mode of Transport: Meet at location
  Cost: $30 per student
- How many students are registering REQUIRED
  Add up to 3 students per registration. Please only register students of which you are the parent / legal guardian.
  Please fill out this field.
  
  Student 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Email Please enter an email address.
  
  '24-'25 Grade REQUIRED Please fill out this field.
  
  Gender / Sex REQUIRED Please fill out this field.
  
  Is there knowledge you can share with us to help serve your child best?
  
  Student 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Email Please enter an email address.
  
  '23-'24 Grade REQUIRED Please fill out this field.
  
  Gender / Sex REQUIRED Please fill out this field.
  
  Is there knowledge you can share with us to help serve your child best?
  
  Student 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Email Please enter an email address.
  
  '23-'24 Grade REQUIRED Please fill out this field.
  
  Gender / Sex REQUIRED Please fill out this field.
  
  Is there knowledge you can share with us to help serve your child best?
- How many parent contacts would you like to register? (up to 2) REQUIRED
  Add up to 2 parents or guardians for your student(s)
  Please fill out this field.
  
  Parent 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Primary Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Mailing Address Line 1 REQUIRED Please fill out this field. Please enter valid data.
  
  Mailing Address Line 2 Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Parent 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Primary Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Mailing Address Line 1 REQUIRED Please fill out this field. Please enter valid data.
  
  Mailing Address Line 2 Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Emergency Contact Information
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Relation to Student REQUIRED Please fill out this field. Please enter valid data.
- Optional Medical Information
- Medicine my child is taking at present Please enter valid data.
- Family Health Plan Carrier Please enter valid data.
- Policy # Please enter valid data.
- Family Doctor Please enter valid data.
- Doctor's Phone Number Maximum 20 characters Please enter a phone number.
- Indemnity Agreement
- I indemnify Immaculate Heart of Mary Church and the Archdiocese of St. Paul/Minneapolis from any claims or lawsuits brought against Immaculate Heart of Mary Church/ Archdiocese of St. Paul/Minneapolis by me, my child or others, that arises out of any behavior by my child at the events/activities of youth nights. I also agree to pay reasonable attorney’s fees or expenses incurred by Immaculate Heart of Mary Church and the Archdiocese in defense of such a claim/lawsuit.
  I Agree Please select this field.
- Emergency Medical Treatment
- In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by a doctor or hospital.
  I Agree Please select this field.
- Media Release
- I have read the Authorization, Consent and Release for use of visual likeness and original works of minors, and have had the opportunity to consider their terms and understand them. I grant permission to Immaculate Heart of Mary to use pictures/images of child(ren)in bulletin website and marketing materials.
  I Agree Please select this field.
- Social Media and Electronic Communications Authorization
- I have read the Disclosure, Authorization and Consent for Social Media or other Electronic Communication involving minors and have had the opportunity to consider their terms and understand them. I grant permission to Immaculate Heart of Mary to use pictures/images of child(ren)in bulletin website and marketing materials.
  I Agree Please select this field.
- Parent / Guardian Signer
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.
Submit

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