VBS Registration

Parent/ Guardian First and Last Name REQUIRED Please fill out this field. Please enter valid data.

Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Email REQUIRED Please fill out this field. Please enter an email address.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Days Attending REQUIRED ALL Monday Tuesday Wednesday Thursday Friday Please fill out this field.

Home Church Please enter valid data.

Children will be in multi-aged crews. Requests to be with siblings and friends can be indicated & we will do our best to honor all requests but cannot offer guarantees. Group with sibling Group away from sibling

Request to be with a friend. Print the name of friend here. Please enter valid data.

Child 1 First Name REQUIRED Please fill out this field. Please enter valid data.

Child 1 Last Name REQUIRED Please fill out this field. Please enter valid data.

Child 1 Sex REQUIRED Male Female Please fill out this field.

Child 1 Birthdate REQUIRED Please fill out this field. Please enter a date.

Child 1 Grade Completed June 2025 REQUIRED Please fill out this field.

List any allergy, medical, or dietary information we should be aware of here. If none, type none. REQUIRED Please fill out this field. Please enter valid data.

Child 2 First Name Please enter valid data.

Child 2 Last Name Please enter valid data.

Child 2 Sex Male Female

Child 2 Birthdate Please enter a date.

Child 2 Grade Completed June 2025

List any allergy, medical, or dietary information we should be aware of here. Please enter valid data.

Child 3 First Name Please enter valid data.

Child 3 Last Name Please enter valid data.

Child 3 Sex Male Female

Child 3 Birthdate Please enter a date.

Child 3 Grade Completed June 2025

List any allergy, medical, or dietary information we should be aware of here. Please enter valid data.

Child 4 First Name Please enter valid data.

Child 4 Last Name Please enter valid data.

Child 4 Sex Male Female

Child 4 Birthdate Please enter a date.

Child 4 Grade Completed June 2025

List any allergy, medical, or dietary information we should be aware of here. Please enter valid data.

LaSalle Daycare: REQUIRED

Children at the LaSalle daycare have the option of being picked up by the VBS crew and then returned back to daycare once VBS is finished.

Yes, I need my child/ren picked up from the LaSalle Elementary daycare and returned when VBS is finished by a member of the VBS crew or daycare Staff. No, I do not need my child/ren picked up from LaSalle daycare. Please fill out this field.

PARENTS, join the adventure in the wilderness! Check any of the following options assist with Totally Catholic Bible School!

Please assist with VBS this year by checking one of the following options to join the fun!

Station Leader Help with Registration Be a Camera Person Assist with items from home BEFORE VBS

INSTRUCTIONS-
Please scroll down to read and answer each of the following necessary consent and liability waivers-
1. Consent and Liabilty Waiver
2. Emergency Medical Treatment Permission
3. Emergency Contact, Doctor, and Insurance Information
4. Illness Notification
5. Nonprescription Medication Permission
6. Allergy Information
7. Asthma Information
8. Prescribed Diet Information
8. Limitations Information
9. Other Medical Information
10. Media Release
11. Electronic Signature

CONSENT AND LIABILITY WAIVER
This Consent and Liability waiver is required for and serves both on-site programs and off-site/field trip events/activities for the stated program year. I grant permission for my child to participate in parish/cluster events this year that may require transportation to a location away from the parish/cluster site. The activities will take place under the guidance and direction of parish/cluster employees and/or volunteers. As a parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above-named minor (“Participant”). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend its officers, directors of the parish/cluster and agents, and the Archdiocese of Dubuque, chaperones, or representatives associated with the events, arising from or in connection with my child attending the events or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the parish/cluster, its officers, directors and agents, and the Archdiocese of Dubuque, chaperones, or representatives associated with the events for reasonable attorney’s fees and expenses which they may incur in any action I/we may bring against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/cluster or the Archdiocese of Dubuque.

Consent and Liability Waiver REQUIRED Yes, I have read and agree to the terms in the Consent and Liabilty Waiver above. No, I do not agree to the Consent and Liability Wavier electronically. I understand I must sign a paper copy of the Wavier for the child to participate in the event. Please fill out this field.

EMERGENCY MEDICAL TREATMENT PERMISSION
I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. In the event of an emergency, I hereby give permission to transport my child 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, if you are unable to reach me contact the emergency contacts/locations as listed in this online registration process.

Emergency Medical Treatment Permission REQUIRED Yes, I give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. No, I do not give permission to transport my child to a hospital for emergency medical or surgical treatment. Please fill out this field.

Emergency Contact Name and Relationship REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact Phone REQUIRED Please fill out this field. Please enter a phone number.

Family Doctor REQUIRED Please fill out this field. Please enter valid data.

Family Doctor Phone REQUIRED Please fill out this field. Please enter a phone number.

Family Health Plan Carrier REQUIRED Please fill out this field. Please enter valid data.

Family Health Plan Policy # REQUIRED Please fill out this field. Please enter valid data.

ILLNESS NOTIFICATION
In the event it comes to the attention of the parish, its officers, directors and agents and the Archdiocese of Dubuque, chaperones, or representatives associated with any activity or while at parish that my child becomes ill with symptoms such as vomiting, sore throat, fever, diarrhea, I want to be notified.

Illness Notification REQUIRED Yes, I want to be notified in the event that my child becomes ill. No, I don't want to be notified in the event that my child becomes ill. Please fill out this field.

If you answered yes above, please provide the name and number to call. Please enter valid data.

NONPRESCRIPTION MEDICATION PERMISSION REQUIRED Yes, I hereby grant permission for nonprescription medication (such as ibuprofen, Tylenol, throat lozenges, etc.) to be given to my child in the event a condition arises after my child is already in attendance at a parish/cluster program/activity. No, I do not grant permission for nonprescription medication (such as ibuprofen, Tylenol, throat lozenges, etc.) to be given to my child in the event a condition arises after my child is already in attendance at a parish/cluster program/activity. Please fill out this field.

ALLERGY INFORMATION REQUIRED Yes, This child has allergic reactions to medications, foods, plants, insects etc. Please provide a list of known allergies, reactions, and directives. No, this child does not have allergic reactions to medications, foods, plants, insects etc. Please fill out this field.

ASTHMA INFORMATION REQUIRED Yes, this child utilizes asthma or airway constriction prescription medication. Please provide the parish/cluster with written information on the child’s asthma condition. No, this child does not utilize asthma or airway constriction prescription medication. Please fill out this field.

PRESCRIBED DIET INFORMATION REQUIRED Yes, this child has a medically prescribed diet. Please provide the parish/cluster with additional written information on the diet. No, this child does not have a medically prescribed diet. Please fill out this field.

LIMITATIONS INFORMATION REQUIRED Yes, this child has physical limitations that require accommodations by the parish/cluster. Please provide the parish/cluster with additional written information on the limitations. No, this child does not have any physical limitations that require accommodations by the parish/cluster. Please fill out this field.

OTHER MEDICAL INFORMATION REQUIRED Yes, this child has other medical conditions about which the parish/cluster should be aware. Please provide the parish/cluster with additional written information on the medical conditions. No, this child does not have any other medical conditions about which the parish/cluster should be aware. Please fill out this field.

MEDIA RELEASE AND AUTHORIZATION REQUIRED Yes, I understand that by responding “Yes” I hereby grant authority to my child’s parish/cluster for the use of any videos, photos, or similar items in social media or on a parish/cluster web page. No, I do not grant authority to my child's parish/cluster for the use of any videos, photos, or similar items in social media or on a parish/cluster web page. Please fill out this field.

ELECTRONIC SIGNATURE REQUIRED No = I am unwilling to sign this form electronically. I understand that I must contact the parish office for a hardcopy of the liability waiver before my child can participate in the program. Yes = I am the parent or guardian of the participant named above and have the legal authority to execute the above permission(s). I consent to signing this document electronically as demonstrated by typing my name and checking “Yes” here. Please fill out this field.

Parent/ Guardian First Name REQUIRED Please fill out this field. Please enter valid data.

Parent/ Guardian Last Name REQUIRED Please fill out this field. Please enter valid data.

VBS Registration Fee REQUIRED Please fill out this field.

Service Fee REQUIRED 1.0 – Service Fee for paying online Please fill out this field.

St. Jude Catholic Church

Cedar Rapids, IA

VBS Registration