Wednesday Night Faith Formation Registration

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

Father's Full Name REQUIRED Please fill out this field. Please enter valid data.

Mother's Full 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.

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

Alternate Phone Number Please enter a phone number.

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

Children/Youth to Register:

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 Birth Date REQUIRED Please fill out this field. Please enter a date.

Child 1 Sex REQUIRED Please fill out this field.

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

Child 1 Grade REQUIRED Please fill out this field.

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

Child 2 First Name Please enter valid data.

Child 2 Last Name Please enter valid data.

Child 2 Birth Date Please enter a date.

Child 2 Sex

Child 2 School Please enter valid data.

Child 2 Grade

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 Birth Date Please enter a date.

Child 3 Sex

Child 3 School Please enter valid data.

Child 3 Grade

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

Do any of the children have any type of learning difficulty? REQUIRED Yes No Please fill out this field.

Do any of the children attend special education classes or utilize a 504 or IEP plan in their public school? REQUIRED Yes No Please fill out this field.

If yes to any of these questions, please give the name of the child, any information we may need, and how we can help. Please enter valid data.

If you are new to our program, please indicate to level of prior Faith Formation training or experience they have. Please also provide a copy of each child's Baptismal Certificate to the parish office. Please enter valid data.

I authorize the following to pick up my children (any non-parent/ guardian who plans to pick up the children must be listed): Please enter valid data.

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.

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. 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 Number 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 Number 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.

ELECTRONIC SIGNATURE REQUIRED 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. 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. Please fill out this field.

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

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

Faith Formation Tuition REQUIRED Please fill out this field.

St. Jude Catholic Church

Cedar Rapids, IA

Wednesday Night Faith Formation Registration