Sacred Heart of Jesus

Form: Covecrest


2017 9th-12th Grade Covecrest Registration Form
Camp Dates: July 2-7, 2017

To save a camp spot a $200.00 non-refundable deposit is required.  Please make checks to Sacred Heart of Jesus and return to 200 W. Main St. Broussard, LA 70518
Total Cost for Camp is $700.00 (Parish fundraising will be incorporated to offset camp cost.)  Cost includes food, transportation, camp fees and 3 T-Shirts.

Student Information
Date of Birth *
Date of Birth
Student Cell Phone
Student Cell Phone
Sacrements Received *
Parent Information
Guardian Address 1 (required) *
Guardian Address 1 (required)
Guardian Address 2 (optional)
Guardian Address 2 (optional)
Cell Phone 1 (required) *
Cell Phone 1 (required)
Cell Phone 2 (optional)
Cell Phone 2 (optional)
Emergency Contact *
Emergency Contact
Please provide contact information of someone other than parent/guardian. This information will be used if parent/guardian cannot be reached.
Emergency Contact Cell Phone *
Emergency Contact Cell Phone
I have read and agreed to the Parish Liability Waiver, seen below. *
Date of consent and release *
Date of consent and release
Only 20 spots available. All additional students will be on a waiting list.

Parish Liability Waiver
I request that the Sacred Heart of Jesus program allow my child(ren) to attend Life Teen Camp Covecrest from July 2-7, 2017 at Camp Covecrest Tiger, GA. In consideration for my child's participation, on behalf of myself, my child, and our heirs, assigns, executors and personal representatives, I hereby release, absolve, indemnify and agree to hold harmless Sacred Heart of Jesus the Roman Catholic Church of the Diocese of Lafayette, and any and all of their officers, directors, agents, employees’ representatives, volunteers, or sponsors from any and all liability for any and all injury that may arise out of participation in this activity. I also authorize the supervisor of the Life Teen Retreat program or his/her designee to provide first aid or similar care in non-emergency situations, and to seek emergency medical assistance when they deem it necessary, for which I will be financially responsible. Further, I give permission to have photos taken of my child for the purpose of parish use.