"*" indicates required fields Chaperone InformationChaperone Full Name* First Last Suffix Chaperone Preferred First Name*Appropriate names only will be used on his/her nametag instead of their First Name. Please do not include the last name in this field. First Birthdate*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemaleChaperone Email* Enter Email Confirm Email Name of Parish/School Chaperoning*Bishop McLaughlin Catholic High SchoolChrist the King Catholic Church, TampaCorpus Christi Catholic Church, Temple TerraceEspiritu Santo Catholic Church, Safety HarborOur Lady of Grace Catholic Church, Beverly HillsOur Lady of the Rosary Catholic Church, Land O'LakesSt. Anthony of Padua Catholic Church, San AntonioSt. Jerome Catholic Church, LargoSt. Joan of Arc Catholic Church, Spring HillSt. Joseph Catholic Church, ZephyrhillsSt. Lawrence Catholic Church, TampaSt. Mark the Evangelist Catholic Church, TampaSt. Matthew Catholic Church, LargoSt. Michael the Archangel Catholic Church, ClearwaterSt. Patrick Catholic Church, TampaSt. Paul Catholic Church, TampaSt. Rita Catholic Church, Dade CitySt. Stephen Catholic Church, RiverviewSt. Thomas Aquinas Catholic Church, New Port RicheySt. Timothy Catholic Church, LutzTampa Catholic High SchoolChaperone Mailing Address* Street Address Address Line 2 City STAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code T-Shirt Size*SmallMediumLargeX-Large2X-Large3X-Large4X-LargeHow many GSPs have you attended?*01234+Emergency Contact InformationEmergency Contact's Full Name* First Last Emergency Contact's Phone*Please enter only the one best number here and please include the area code, e.g.: XXX-XXX-XXXXDietary and Medical InformationDo you have an Dietary Restrictions or Food Allergies?* Yes No The leaders of the Good Samaritan Project will provide, to the best of their ability, special meals where medically required. We will try to provide alternatives but are not able to provide special meals based on nutritional lifestyles or choices. GSP cannot rule out cross-contamination of medically required meals. If dangerous allergic reactions could occur, GSP suggests those participating consult with their group leader about bringing supplemental food.Dietary Restrictions/Food Allergies* Gluten-Free Dairy-Free Vegetarian Vegan Nut Allergy Other Please Specify Allergy/Restriction Type*e.g.: Allergic to mushrooms, almonds and strawberries (Tap the + to add more.)Allergy Add RemoveDo you have any Medicinal Allergies?*e.g.: Allergic to penicillin Yes No Medicinal Allergies*(Tap the + to add more.) Add RemoveDo you have any Physcial Restrictions?*e.g.: asthma, diabetes, depression, ADHD Yes No Physical Restrictions*(Tap the + to add more.) Add RemoveAcknowledgementsPlease read the acknowledgements and check the boxes to confirm you have read and agree to the statements they accompany.Consent* I agree to review to the Code of Conduct and sign off on agreeing to the terms.*EmailThis field is for validation purposes and should be left unchanged. Δ
