St. John the Evangelist
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.)
Indicates required field
Full name of student (one form per child please)
If your child is 5 by 8/1/17, will he/she be attending kindergarten in the 2016/17 school year?
Birth Date of Child (mm/dd/yyyy):
Child's Age as of 8/1/17:
number at which you can most easily be reached
Registered Parishioner - active
Registered Parishioner - inactive
full name of student's father
full name of student's mother
Secondary Phone Number
Classroom Assistant (teens can volunteer for this position)*
*If you volunteer for these opportunities, all children in the program Pre-K through 8th grade will be free!
Special Needs/Medical Conditions of Student:
Is there anything else we need to know about your child?
Medical Release Agreement
I have read the Medical Release statement listed above and fully understand its content and meaning
I do not agree with the Medical Release statement (agreement is required for participation)
please read the medical statement above before denoting your agreement
Medical Form - Parent's Employment:
place of employment for one or both parents
Medical Form - Work Phone Number(s):
work phone number(s) for one or both parents
Medical Form - Parent Work Address(es):
full work address(es) for working parent(s)
Medical Form - Other Emergency Contact:
name/relationship/phone # of non-parent emergency contact
Medical Form - Child's Medications:
any medications the child is taking that would need to be known in any emergency situation
Medical Form - Child's Allergies/Chronic Conditions:
e.g. seizures, diabetes, peanut allergy, other conditions
Medical Form - Medical Insurance Company Name:
name of insurance company covering the child
Medical Form - Insurance Policy Number:
policy and group numbers on child's insurance card
Medical Form - Covered Insured's Name:
name of the parent/guardian covering the child with insurance
Medical Form - Name of Child's Physician:
name of child's primary physician
Medical Form - Phone Number of Child's Physician:
phone number of child's primary physician
I will pay online*
I will send a check
I need financial assistance
*If you chose to pay online, please follow this link:
. You can also find this link on the homepage (the "Donate or Make a Payment" button).
Don't forget to click submit!
I Have Called You By Name
9080 CINCINNATI-DAYTON RD
WEST CHESTER, OH 45069-3129
PARISH OFFICE: (513) 777-6433