This Page is for Invitation Only Guests

If you have not received an invitation, please contact christiebesancenez@archstl.org

The Fleur de Lis Supper Dance Membership $300.00.

After June 30th, the fee becomes $325.00 if space remains.

Invitation Page Supper Dance - Revised 2024

"*" indicates required fields

Child Information

Child’s Formal Name – In Full*

Preferred Name*

High School attending in the Fall*

Parent Information

Formal Name – In Full*

Address*
Street Address City State / Province / Region ZIP / Postal Code

Best Email*

Best Phone Number*

Child’s Food Allergies*

THE FLEUR DE LIS RELEASE, HOLD HARMLESS AND MEDIA AUTHORIZATION AGREEMENT

As parent(s) or legal guardian(s) of*

(“Participant”), I/we do hereby consent to Participant’s participation in The Fleur de Lis Supper Dance (“Supper Dance”).

II am/We are fully aware of the risks and hazards connected with the Supper Dance, which I/we understand could lead to bodily injury to Participant and/or, among other things, loss or damage to Participant’s property. In consideration for allowing Participant to participate in the Supper Dance, I/we hereby release, discharge and hold harmless The Fleur de Lis and all of its respective employees, volunteers, agents and affiliates (hereinafter referred to as “Releasees”) from any and all liability, claims, demands, actions and/or causes of action whatsoever arising out of or related to any loss, damage, or bodily injury that Participant may sustain, or to any property which I/we own or Participant owns, whether caused by the negligence of the Releasees, or otherwise, while participating in the Supper Dance, or on route to or from the destination where the Supper Dance are being conducted.

I/We further agree to comply with any and all rules or policies of The Fleur de Lis and should it be necessary for Participant to return home due to medical reasons, disciplinary actions or otherwise, I/we agree to be responsible for transportation of Participant.

In case of medical emergency, I/we, the undersigned, do hereby request and consent to examination and treatment of Participant by any duly licensed medical professional or health care facility, and further accept full financial responsibility for charges for same, including ambulance charges.

In addition, I/we, grant the Fleur de Lis my/our permission to use any photographs or video taken of Participant at any Fleur de Lis event, for any legal use, including but not limited to, publicity, copyright purpose, illustration, advertising, social media or web content. I/we understand that no royalty, fee or other compensation shall become payable to me or Participant by reason of such use. Furthermore, I understand that The Fleur de Lis may associate such image with the first name only of Participant.

IN SIGNING THIS RELEASE, HOLD HARMLESS AND MEDIA AUTHORIZATION AGREEMENT, I/WE ACKNOWLEDGE AND REPRESENT THAT I/WE HAVE READ THE FOREGOING AGREEMENT, have legal authority to sign this Agreement, understand all its provisions, and sign it voluntarily as my/our own free act and deed. I/We warrant that no oral representations, statements, or inducements apart from the foregoing written agreement, have been made.

Date*
MM slash DD slash YYYY

Parent/Guardian Signature*

Date*
MM slash DD slash YYYY

Parent/Guardian Signature*

I promise to abide by the rules and policies of The Fleur de Lis

Student Participant’s Signature*

Student participant’s Cell Number*

Date*
MM slash DD slash YYYY

In the event you cannot be reached, please provide an emergency contact:

Print Name*

Cell Number*

Comments
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