St. John the Evangelist
     Catholic Church
  • Home
  • Parish Info
  • Events
  • Organizations
  • Ministries
  • Faith Formation
  • Media
513-777-6433
    Picture
    Early Bird Ends July 27
    Open House: August 27
    First Day of Classes: Sept 10
    Last Class: April 15, 2018
    Deadline for Registering: August 14
    ​

    Early Childhood Registration Form 2017-2018

    Archdiocese of Cincinnati Release and Indemnification and Medical Power of Attorney Agreement:

    1. I am the lawful parent or guardian of the child being enrolled on this form. I give permission for my child to participate in the activity described herein, and release from all liability and indemnify the Archbishop of Cincinnati (“the Archbishop”), both individually and as trustee for the Archdiocese of Cincinnati and all parishes within the Archdiocese, and their officers, agents, representatives, volunteers, and employees from any and all liability, claims, judgments, cost or expenses, including attorney fees, arising out of any injury or illness incurred by my child while participating in or traveling to or from the activity.

    2. I agree to instruct my child to cooperate with the Archbishop or his agents in charge of the activity.

    3a. I appoint the Archbishop or his agents who are acting as leaders of the activity as my attorney in fact to act for me in my name and my behalf, in any way that I would act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity or related travel:

    (i) To give any and all consents and authorizations to any physicians, dentist, hospital or other persons or institutions pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other emergency actions as our attorney shall deem necessary or appropriate for the best interest of the child.

    (ii) I understand that the agents of the Archbishop will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my child.

    3b. The powers and authority granted herein may be revoked by me by written notice delivered to the Archbishop or his agents who are then acting or who have previously acted hereunder. Without such written notice, this power of attorney shall not be affected by my disability, incapacity or adjudicated incompetence. This power of attorney shall lapse automatically at the end of above said time period.

    4. I agree that the Archbishop or his agents may use my child’s portrait or photograph for promotional purposes and office functions, and hereby release the Archbishop and his agents from any liability resulting from such use.

    (Please indicate your understanding and agreement of this information in the field below.)
    Full name of student (one form per child please)
    number at which you can most easily be reached
    full name of student's father
    full name of student's mother
    *If you volunteer for these opportunities, all children in the program Pre-K through 8th grade will be free!
    please read the medical statement above before denoting your agreement
    place of employment for one or both parents
    work phone number(s) for one or both parents
    full work address(es) for working parent(s)
    name/relationship/phone # of non-parent emergency contact
    any medications the child is taking that would need to be known in any emergency situation
    e.g. seizures, diabetes, peanut allergy, other conditions
    name of insurance company covering the child
    policy and group numbers on child's insurance card
    name of the parent/guardian covering the child with insurance
    name of child's primary physician
    phone number of child's primary physician

    *If you chose to pay online, please follow this link: https://stjohnwc.weshareonline.org/#. You can also find this link on the homepage (the "Donate or Make a Payment" button).

    Don't forget to click submit!
Submit
I Have Called You By Name
Parish Theme

9080 CINCINNATI-DAYTON RD 
WEST CHESTER, OH 45069-3129 
PARISH OFFICE: (513) 777-6433
✕