ST. JOHN THE EVANGELIST CATHOLIC CHURCH
Summer Faith Formation Registration Form
Summer Faith Formation
is a two-week summer session with two to three seasonal follow-up sessions during the remainder of the school year. The children are grouped by grade levels.
SFF class dates and times are June 9-20 from 9 a.m. to 12:30 p.m. Follow-up sessions includes Generations of Faith (dates and times TBA).
St. John Education Center
$80 per child
(Fees can be paid by check or online.)
Registration deadline is May 31, 2014.
Please complete this entire form (registration and medical release form) for every child being registered. Please be sure to pay the $80 fee (per child) by mailing it or bringing it into the parish office or by clicking on the "We Share" button on our website. Thanks!
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
Electronic Signature of Parent or Guardian
Student's Grade Level:
school attended by student for 2013-2014 school year
Student's Date of Birth (mm/dd/yyyy):
Yes (please send copy of sacramental certificates to St. John prior to the program start date)
Sacramental Participation 2014-2015:
First Eucharist (2nd grade or higher)
First Reconciliation (usually 4th grade)
home address of student
best phone number(s) to contact parent(s)
primary family email address
Parent/Guardian 1 Name:
Parent/Guardian 1 Relationship to Student:
Marital Status of Parent/Guardian 1:
Religion of Parent/Guardian 1:
Parent/Guardian 2 Name:
Parent/Guardian 2 Relationship to Student:
Marital Status of Parent/Guardian 2:
Religion of Parent/Guardian 2:
Childcare for Catechists
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 parent(s)
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 an 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 for child's primary physician
I will pay online*
I will send a check
I need financial assistance
please choose your payment method
*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!
We Are the Body of Christ
9080 CINCINNATI-DAYTON RD
WEST CHESTER, OH 45069-3129
PARISH OFFICE: (513) 777-6433