VBS Registration

Household Information

Parent/Guardian 1 Name

Parent/Guardian 1 Cell Phone

Parent/Guardian 2 Name

Parent/Guardian 2 Cell Phone

Home Phone

Address

Home Parish

Child 1 Information

Child 1 Name

Child 1 Age

Child 1 Allergies or Conditions that the SFA staff should be aware of:

Child 2 Information

Child 2 Name

Child 2 Age

Child 2 Allergies or Conditions that the SFA staff should be aware of:

Child 3 Information

Child 3 Name

Child 3 Age

Child 3 Allergies or Conditions that the SFA staff should be aware of:

Child 4 Information

Child 4 Name

Child 4 Age

Child 4 Allergies or Conditions that the SFA staff should be aware of:

Emergency Contact and Pick-Up Information

Emergency Contact Name (when Parent/Guardian cannot be reached)

Emergency Contact Home Phone

Emergency Contact Cell Phone

Person Picking up child(ren) if other than Parent/Guardian

Pick-up Person's Home Phone

Pick-up Person's Cell Phone

Waiver and Consent

Diocesan Event Waiver: I/We, the parents of the above-named youth, hereby give my/our approval for his/her participation in the above event. I/We assume all risks and hazards incidental to the conduct of the activities and transportation to and from the event. I/We do further hereby waive, release, absolve, indemnify, and hold harmless the Bishop to the Catholic Diocese of Evansville, St. Francis of Assisi Parish, Rev. Crispine Adongo, Pastor, and any of their respective affiliates, successors, agents, employees, members, and representatives, adult sponsors, and other volunteers involved in the activities and transportations associated with the event from any and all claims, including claims of personal injury to my/our youth or property damage, under any theory of law (including negligence, but not reckless or intentional conduct) in any way resulting from or arising in connection with the activities and/or transportation to and from the event. It is understood and agreed that neither the Parish, the Catholic Diocese of Evansville, any respective affiliate, successors, agent, employee, member, representative, adult sponsor, nor other volunteer is the insurer of my child’s health and safety while he/she is at youth functions, engaged in supervised activities, including sports, or being transported in association with the event. I/We understand it to be my/our obligation to provide such insurance as I/we may desire to purchase to protect myself/ourselves and my/our child against the costs of sickness or injury. In case of emergency or serious illness, should the above-named child require medical treatment, and a parent or the designated family physician cannot be contacted, consent is hereby granted for such medical treatment as may be considered necessary in the opinion of the designated medical respondent. I UNDERSTAND THAT MY SIGNATURE RELIEVES THE PARISH, THE DIOCESE, AND ANY AND ALL OF ITS AFFLIATES, SUCCESSORS, AGENTS, EMPLOYEES, MEMBERS, REPRESENTATIVES, ADULT SPONSORS, AND VOLUNTEERS OF ANY AND ALL LIABILITY RELATED TO THE ADMINISTRATION OF ANY PRESCRIBED MEDICATION LISTED ON THE APPLICATION FORM (INCLUDING OVER-THE-COUNTER DRUGS). Further, I/we acknowledge having read, or been made aware of the Diocesan Youth and/or Adult Codes of Conduct, the Diocesan Release for Media Recording, and the Diocesan Off-site Transportation Policy, and I/we agree to be bound by the terms and conditions set forth in those documents (copies available via http://www.evdio.org/dicesan-forms-for-oyaya.html). I acknowledge and understand that any action on behalf of my/our child/dependent that is inconsistent with the Diocesan Code of Conduct may result in appropriate disciplinary action as outlined in those documents. I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement. Parent/Guardian E-Signature

Photo and Video Release: I give permission for the students listed on this registration form to be photographed and/or videotaped in supervised group settings during Vacation Bible School at St. Francis of Assisi Parish. I understand the photos and/or video may be published and/or posted to the following types of publications and social media outlets affiliated with St. Francis of Assisi and The Catholic Diocese of Evansville: Bulletins, newsletters, newspapers, websites, and social media sites. Parent/Guardian E-Signature

Comments

Any Additional Comments?