ST. JOHN THE EVANGELIST CATHOLIC CHURCH
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Vacation Bible School Registration Form
When
: June 22 – June 26, 2020, 9:00am – 12:00pm
Who
: Children entering grades K – 5, in Fall 2020
Where
: St. John Education & Activities Center
Cost
: $15.00 per child (Children of Volunteers attend free!)
VBS registration is first come, first served. Registration will close when capacity is reached (determined by number of adult volunteers). Registering your child(ren) early will ensure a spot reserved for them.
Registrations will be available online beginning May 1, 2020. Payment can be made with check or cash only.
Teen Volunteer Form:
We welcome the assistance of youth, grades 7 and higher (Fall 2020). If you have a teen looking for volunteer service hours, check back for
the teen volunteer form and turn in with your payment.
Please complete this entire form (registration and medical release form) for every child being registered. Please be sure to pay the $15.00 fee (per child) by mailing it or bringing it into the Parish Office by the deadline. Thanks!
St. John the Evangelist Church
Vacation Bible School
Permission, Release and Medical Power of Attorney Form
June 22 - June 26, 2020
ARCHDIOCESE OF CINCINNATI
RELEASE AND INDEMNIFICATION AND MEDICAL POWER OF ATTORNEY
I, the lawful parent or guardian of ___________________________(the “child”), give permission for my child to participate in the activity described on the reverse side, 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.
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:
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.
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.
ACTIVITY INFORMATION
A.
On-Going Program
Church Agency
St. John the Evangelist Parish
Program or Group
Vacation Bible School
Starting Date
Monday, June 22, 2020
Ending Date
Friday, June 26, 2020
Registration Fee
$15.00 per child
Usual Location
St. John Education Center
Usual time
9:00am – 12:00pm
Routine Activities
Music, Skits, Games, Snacks
,
Large & Small Group Gatherings
Group Leader
Mary Montour, Pastoral Associate, Children’s Faith Formation
Telephone No.
513-755-4973, or, 513-777-6433, x.118
*
Indicates required field
Electronic Signature of Parent or Guardian
*
Child 1 Name:
*
First
Last
Child 1 Grade Level in Fall 2020:
*
K
1
2
3
4
5
Child 2 Name:
*
First
Last
Child 2 Grade Level in Fall 2020:
*
K
1
2
3
4
5
Child 3 Name:
*
First
Last
Child 3 Grade Level in Fall 2020:
*
K
1
2
3
4
5
Child 4 Name:
*
First
Last
Child 4 Grade Level in Fall 2020:
*
K
1
2
3
4
5
Address
*
Line 1
Line 2
City
State
Zip Code
Country
home address of student
Phone Number
*
best phone number(s) to contact parent(s)
Email
*
primary family email address
Parent/Guardian 1 Name:
*
First
Last
Parent/Guardian 1 Relationship to Student:
*
Mother
Father
Step-Mother
Step-Father
Other/Guardian
Parent/Guardian 2 Name:
*
First
Last
Parent/Guardian 2 Relationship to Student:
*
Mother
Father
Step-Mother
Step-Father
Other/Guardian
Volunteer Opportunities
It takes many volunteers for VBS to be a success. All materials are provided and lessons, skits, and songs are scripted.
Teens going into 7th grade and older
are welcome to join the expedition! Questions? Contact Mary Montour,
mmontour@stjohnwc.org
or (513) 777-6433, x.118
Please check all boxes where you can help.
*
Session Leader (crafts, games, bible story, snack activity, video activity)
Group Leader (great for teens)
Donate Snacks
Childcare (if needed)
Set Up (Week prior to June 22 Time TBA)
Tear Down (June 26, 12-2pm)
Song Leader
Medical Form
If you are interested in ordering a t-shirt, return the form and payment to the Parish Office no later than
May 25
.
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
Choose One
*
I will send a check
I need financial assistance
Submit
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