Vacation Bible School 2018

Saint Clare of Assisi Catholic Church
Vacation Bible School Registration Form

Monday, June 25th – Friday, June 29th
9:00 a.m. – 11:30 a.m.
Location: Holy Cross Church

Age 4 through 5th Grade (as of Fall 2018)
Registration fee: $45.00 per child

1Family and Emergency Information > 2Student Information > 3Tuition Payment > 4Payment
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FAMILY INFORMATION

Family Last Name
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Interested in Volunteering Opportunities?

Interested in Volunteering Opportunities? Lead Teacher (18 and older) Station Helper Youth Volunteer (6th grade +)

Please remember that you must have/will need your Safe Haven background check completed by Friday May 25th.
Volunteer Names, Ages, Positions

Please list the names, ages, and desired volunteer positions in this box.
EMERGENCY CONTACT, MEDICAL AND HEALTH INFO AND AUTHORIZATION
Emergency Contact Name OTHER than Parents. Emergency Contact Name OTHER than Parents. First Last
Please enter the name, primary phone number and relationship of the emergency contact. This contact will be used for all students in the family.
Emergency Contact Phone OTHER than Parents. Emergency Contact Phone OTHER than Parents. - ### - ### ####
Emergency Contact Relationship to Student
Family Doctor Family Doctor First Last
Doctor's Phone Number Doctor's Phone Number - ### - ### ####
I hereby warrant that to the best of my knowledge, my child(ren) is/are in good health, and I assume all responsibility for the health of my child(ren). I will not send my child(ren) to classes within 24 hours of him/her having fever, vomiting, and/or diarrhea.

I hereby warrant that to the best of my knowledge, my child(ren) is/are in good health, and I assume all responsibility for the health of my child(ren). I will not send my child(ren) to classes within 24 hours of him/her having fever, vomiting, and/or diarrhea. I have read and accept these terms
In the event of an emergency, I hereby give permission to an authorized representative of the parish to call for EMS transportation of my child(ren) to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor.

In the event of an emergency, and if you are unable to reach me at the number I have provided, call our emergency contact listed above.

In the event of an emergency, I hereby give permission to an authorized representative of the parish to call for EMS transportation of my child(ren) to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor.

In the event of an emergency, and if you are unable to reach me at the number I have provided, call our emergency contact listed above. I have read and accept these terms
Please list all individuals authorized to pick up your child/children. Please include phone numbers.

If parents are the only authorized to pick-up, please enter PARENTS ONLY.
PARENTAL CONTACT INFORMATION
Primary Parental Email for Correspondence

Please enter the email for the primary contact for the family.
Is a custody order currently in effect?

Is a custody order currently in effect? Yes No

If a custody order is in effect, a copy of the order must be submitted to the parish office to be placed on file.
Father's Name Father's Name First Last
Father's Email
Father's Cell Number Father's Cell Number - ### - ### ####
If a custody order is in place, does the Father have custody?

If a custody order is in place, does the Father have custody? Yes No

If a parent does not have custody, they will not be contacted.
Mother's Name Mother's Name First Last
Mother's Email
Mother's Cell Number Mother's Cell Number - ### - ### ####
If a custody order is in place, does the Mother have custody?

If a custody order is in place, does the Mother have custody? Yes No

If a parent does not have custody, they will not be contacted.
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Vacation Bible School 2018

Vacation Bible School 2018

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EMERGENCY CONTACT, MEDICAL AND HEALTH INFO AND AUTHORIZATION

PARENTAL CONTACT INFORMATION

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Vacation Bible School 2018

Vacation Bible School 2018

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Total

EMERGENCY CONTACT, MEDICAL AND HEALTH INFO AND AUTHORIZATION

PARENTAL CONTACT INFORMATION

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Total

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