VBS: Registration Form for Crew Leaders and VBS participants

Monday, June 13 to Friday, June 17, 2022

If you have any questions, please contact the 

Parish Office (440) 428-5164.

Please Fill Out All Required Fields
Child's Name #1
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Child's Gender #1
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Date of Birth of Child #1 //
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Grade in school in 2022-2023 Child #1
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Child's Name #2
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Child's Gender #2
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Date of Birth of Child #2 //
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Grade in school in 2022-2023 Child #2
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Child's Name #3
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Child's Gender #3
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Date of Birth of Child #3 //
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Grade in school in 2022-2023 Child #3
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Crew Leader ( grade in school in 2022-2023)
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Parent's Name
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Parent's Address
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Parent's E-mail
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Parent's Phone -- ext
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Any Known Allergies
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Person Picking Up
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Who will be responsible for picking up child?
Person Picking Up Phone -- ext
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Relationship to Child
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Consent and Release
Consent and Release of Liability for Use of Minor's Likeness and Other Information
I (We) the parent(s) and/or guardian(s)hereby grant consent for Immaculate Conception Church (“Parish”), and/or its agents to record (in writing or otherwise), photograph, audiotape, or videotape my minor child’s name, image, likeness, spoken words, student work, and/or performance, in any form, and to display, release, exhibit, publish, or distribute the same, or any part thereof, for the purpose of and in connection with any material that may be created by or on behalf of the Parish including, without limitation, Parish bulletin boards; the Parish’s weekly bulletin; the Parish’s website; print and electronic media; Parish marketing, public relations and communications materials and/or presentations; and such other uses as may not be contemplated herein, without further notice or compensation as follows:
Please select one
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I further understand that by entering into this informed consent and release, and by granting permission as stated herein, I hereby release Immaculate Conception, Madison, the Diocese of Cleveland, and their respective officers, directors, agents and/or employees from and against any and all liability, loss, damage, costs, claims, and/or causes of action arising out of or related to the above items to which I have consented. I further understand that the Parish and its respective officers, directors, agents and/or employees have no control over use of photographs, videotapes, audiotapes, or other records made by others and/or outside the scope of this consent and release. Finally, in signing below I acknowledge that all recordings, audiotape, videotape, photographic proofs, photographic negatives, positives, and prints shall constitute the property of the Parish.
Parent/Legal Guardian
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Date //
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Emergency Medical Authorization
Child's Name #1
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Child's Name #2
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Child's Name #3
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Phone --
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Address
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To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while attending VBS classes when parents or guardians cannot be reached.
Residential Parent or Guardian
Parent's Name
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Parent's Phone -- ext
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If I cannot be contacted and it is advisable to send my child home due to minor illness or injury, my child can be released to the following:
Name
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Relationship
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Phone -- ext
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Part A or B MUST be completed
PART A: TO GRANT CONSENT FOR I hereby give consent for the following medical care provider to be called
Physician
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Physician's Phone -- ext
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In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by:
Physician's Name
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Facts concerning the child’s medical history, including allergies, medications being taken, and any physical impairment to which a physician should be alerted
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Name of Parent/Guardian Completing This Section
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Date Form Completed //
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PART B: REFUSAL TO CONSENT:
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Name of Parent/Guardian Completing This Section
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Date Form Completed //
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