SERVIO(615) Chaperone Registration

General Information

Name

Gender

Male Female

Birthdate

This address will receive a confirmation email

Phone

Address

Church

Please note that the church you select above will be the church used when making transportation assignments to worksites.

Not including you, how many seat belts do you have? In other words, how many kids can you transport in your vehicle?

For the following sections, please upload the required information.

Driver's License - scan or photo of front of license.

Upload (8MB)

Vehicle Insurance Card - scan or photo of front of card

Upload (8MB)

Vehicle Insurance Card - scan or photo of back of card (if applicable)

Upload (8MB)

T-shirt Size (adult sizes)

XS S M L XL XXL XXXL

Medical Insurance and Emergency Contact Information

Health Insurance Company

ID Number

Group Number

Insurance Provider Phone

Legal Name of Policy Holder

Policy Holder Birthdate

Medical Insurance Card - scan or photo of front of card

Upload (8MB)

Medical Insurance Card - scan or photo of back of card

Upload (8MB)

Emergency Contact

Emergency Contact Phone

Other Health Information

Allergies and Dietary Restrictions

Please list any medicine, environmental, and/or food allergies as well as dietary restrictions in the box above.

Special Medical or Health Considerations

Medications

In the box above, please list all medications, dosage, and frequency.

Most Recent Tetanus Date

Releases and Waivers

Liability Waiver and Medical Release: I agree on behalf of myself, my heirs, assigns, executors, and personal representatives, to hold harmless and defend the Diocese of Nashville, St. Matthew Catholic Church, Holy Family Catholic Church, St. Philip Catholic Church, its officers, directors, agents, employees, or representatives associated with this service opportunity from any and all liability claims, loss or damage arising from or in connection with my participation in this service opportunity. I also give consent for medical treatment deemed necessary by the St. Matthew, Holy Family, and St. Philip Staff and I agree to a transfer to any reasonably accessible hospital or physician’s office. I also remain financially responsible for my medical treatment.

COVID-19 Waiver: I acknowledge that an inherent risk of exposure to COVID-19 exists in any public place where people are present. By participating in this service opportunity, I agree to assume all risks related to my possible exposure to COVID-19 and agree not to hold Holy Family Catholic Church, St. Matthew Catholic Church, St. Philip Catholic Church, the Diocese of Nashville, its officers, directors, agents, employees, or representatives associated with this service opportunity liable for any illness.

By typing my name here, I signify that I agree to the release/waivers detailed above.

Date

Media Waiver Release: I give permission for photos and videos taken of me to be used to promote the Diocese of Nashville, St. Matthew Catholic Church, Holy Family Catholic Church, St. Philip Catholic Church, and Catholic faith leaders. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me because of such use.

By typing my name here, I signify that I agree to the release/waiver detailed above.

Media Waiver Release Date

Work Site Preference

Your options for work sites are as follows:

- Work Project - painting, indoor clean up, maintenance, repair work, outdoor yard work.

- Work With Children - work at day care centers for low-income families.

- Work at Social Service Center - homeless shelter, food distribution center, outreach center.

First Preference

Second Preference

Third Preference

Indicate your level of work experience for the following skills: (Level 1 = no experience, Level 3 = I have done this a few times, Level 5 = very skilled)

Carpentry

Concrete/Masonry

Drywall

Painting

Plumbing

Electrical

Relevant Skills and Certifications

List other areas in which you are skilled in the box above. Additionally, please include any certifications/medical training.

Comments to help us place you as a work site leader.

I understand that by typing my name here, I will not consume alcohol while serving as a chaperone for SERVIO(615).

Payment $50

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

June 1-3, 2021

WHAT:
SERVIO(615) is a service opportunity for current 8th -12th graders. Since we are unable to travel to Mississippi for Servio Deo this summer, we are planning a local mission trip to serve the Nashville area.

Join St. Matthew, Holy Family, and St. Philip Catholic Church Youth Ministries to serve the Lord, the greater Nashville community, and bond in fellowship.

Adults (must be 21) are needed to chaperone, drive teens to worksites, and lead a worksite location. Chaperones will be required to sleep at Holy Family Tuesday and Wednesday night and drive to and lead worksites on Tuesday, Wednesday, and Thursday.

WHERE:
Holy Family Catholic Church will be home base for SERVIO(615).

TRANSPORTATION:
Chaperone vehicles will be used to travel to worksites.

COST:
$50.00

DEADLINE TO REGISTER:
April 15, 2021

In order to complete this form, you will need a credit or debit card, a photo or scanned image of the following: 1) your medical insurance card, 2) your vehicle insurance card, and 3) your driver's license.

PLEASE NOTE, in addition to this online registration, you will need to:
-- Turn in a completed Driver Information Sheet

Questions about chaperoning, contact:
--Holy Family: angele.drouilhet@holyfamilycc.com
--St. Matthew: tjesse@stmatthewtn.org
--St. Philip: jstaley@stphilipfranklin.com

Questions about this registration: Contact Deanna Ziesig at deanna.ziesig@holyfamilycc.com

SERVIO(615) Chaperone Registration

Description

Please Fix the Following