2846 Hubbard Rd, Madison OH 44057 |
(440) 428-5164
Menu
Close
Home
Online Giving
Back
Create New Account
Home & User Login
Quick Give
Online Giving Security
Online Giving FAQs
About Online Giving
Contact Us
PSR
Back
PSR
Calendar
Re-Registration
2nd Grade Sacramental Preparation
Confirmation
Vacation Bible School (VBS)
Guidelines for Families of Homeschooled Children
Newcomers
Back
Welcome
Our Faith
Becoming Catholic
Returning Catholics
Learn More
Our Faith
Back
Our Faith
Sacraments
Being Catholic Today
What is the Catholic Church?
We are the Church
What Do Catholics Believe?
Bulletin
Parish Life
Back
Parish Life
Calendar
Photos
Youth Group
About Our Parish
Our Faith
Sacraments
Bulletin
Ministries
Ministries
Contact
Back
Staff
Directions
Contact Us
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
First Name*
Last Name*
Child's Gender #1
Required*
Male
Female
Date of Birth of Child #1
Required*
Month
January
February
March
April
May
June
July
August
September
October
November
December
/
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
Grade in school in 2022-2023 Child #1
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Child's Name #2
First Name
Last Name
Child's Gender #2
Male
Female
Date of Birth of Child #2
Month
January
February
March
April
May
June
July
August
September
October
November
December
/
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
Grade in school in 2022-2023 Child #2
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Child's Name #3
First Name
Last Name
Child's Gender #3
Male
Female
Date of Birth of Child #3
Month
January
February
March
April
May
June
July
August
September
October
November
December
/
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
Grade in school in 2022-2023 Child #3
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Crew Leader ( grade in school in 2022-2023)
6th
7th
8th
9th
10th
11th
12th
Parent's Name
First Name*
Last Name*
Parent's Address
Street 1*
Street 2
City*
State*
-- select --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
None--International
Zip*
Parent's E-mail
Required*
Parent's Phone
Required*
-
-
ext
--select--
Home
Mobile
Work
Any Known Allergies
Required*
Person Picking Up
First Name*
Last Name*
Who will be responsible for picking up child?
Person Picking Up Phone
Required*
-
-
ext
--select--
Home
Mobile
Work
Relationship to Child
Required*
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
Required*
Please make a selection
I consent to all of the above.
I do not consent to any of the above.
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
First Name*
Last Name*
Date
Required*
Month
January
February
March
April
May
June
July
August
September
October
November
December
/
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
Emergency Medical Authorization
Child's Name #1
First Name*
Last Name*
Child's Name #2
First Name
Last Name
Child's Name #3
First Name
Last Name
Phone
Required*
-
-
--select--
Home
Mobile
Work
Address
Street 1*
Street 2
City*
State*
-- select --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
None--International
Zip*
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
First Name*
Last Name*
Parent's Phone
Required*
-
-
ext
--select--
Home
Mobile
Work
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
First Name*
Last Name*
Relationship
Required*
Phone
Required*
-
-
ext
--select--
Home
Mobile
Work
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
First Name*
Last Name*
Physician's Phone
Required*
-
-
ext
--select--
Home
Mobile
Work
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
First Name*
Last Name*
Facts concerning the child’s medical history, including allergies, medications being taken, and any physical impairment to which a physician should be alerted
Required*
Name of Parent/Guardian Completing This Section
First Name*
Last Name*
Date Form Completed
Required*
Month
January
February
March
April
May
June
July
August
September
October
November
December
/
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
PART B: REFUSAL TO CONSENT:
I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the VBS Administrator to take the following action:
Name of Parent/Guardian Completing This Section
First Name*
Last Name*
Date Form Completed
Required*
Month
January
February
March
April
May
June
July
August
September
October
November
December
/
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
It may take a moment for your information to be submitted.
Online Giving
Secure and Convenient
Donate now!