Contagion 2023

* Required information

Student Information

* First Name:
* Last Name:
* Cell Phone:
* Email Address:
* Confirm Email Address:
* Address 1:
Address 2:
* City:
* State:
* ZIP Code:
* Country:
*
What Grade Are You Currently In?
- 7th
- 8th
- 9th
- 10th
- 11th
- 12th
- Adult/Out of High School
* What's Your Date of Birth? (select the YEAR first, then CLICK ON the date in the correct month)

Type	Fee
Event fee	$25.00

*
I agree to act responsibly and considerately during this event. I will respect the rules and laws of the area. I will maintain contact with event’s leaders and will follow the rules of behavior they establish.
- Yes
- No

*
- I certify that I am the parent or legal guardian of the above named student and I consent to my child’s participation in this event. - I recognize that I will be financially responsible for medical care that may result from any injury or illness which my child may sustain or succumb to while participating in this activity. - I hereby consent to emergency medical care to be provided for my child in the event that such care should become necessary in the course of this event.
- Yes
- No
*
- I hereby release The Episcopal Church, The Diocese of Fond du Lac, St. Thomas Church, and all adult leaders acting on its behalf from any and all claims or demands which I or my child may have as a result of participation in this event. - I hereby give permission for my child to ride in any vehicle as authorized by the leaders of this event.
- Yes
- No

Insurance Company Name (you do not need to have insurance to participate in this event but if you have insurance, please include the information here)
Insurance Policy Number
Name of Insurance Policy Holder

Pay with Credit Card
Pay By Check
Please make check payable to:
St. Thomas Church
226 Washington Street
Menasha, WI 54952
Pay at Door