Steubenville 2024 Registration

Please complete the following for the parent/guardian contact:

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

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

Street 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.

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

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

Number of Participants You Are Registering REQUIRED Please fill out this field.
Participant 1
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Address if different than parent/guardian
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Medications:
  My child is taking medications at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage are as follows:
- Medication Information
- Medication Option: please select one REQUIRED No medication of any type may be given to my child except in life-threatening situation. I hereby grant permission for non-prescription medication to be given to my child if deemed appropriate. Please fill out this field.
- Please list any food, medication, or other allergies for this child. Please enter valid data.
- Date of last tetanus/diptheria immunization REQUIRED Please fill out this field. Please enter valid data.
- Please list any physical limitations this child has that might impact his/her participation in this conference or trip to Valleyfair. Please enter valid data.
- Is child subject to homesickness, emotional reactions to new situations, bedwetting, sleepwalking, fainting or any similar concerns? Please enter valid data.
- Has child recently been exposed to any illnesses or diseases such as chicken pox, mumps, measles, etc? If so, please give date of exposure. Please enter valid data.
- Is there anything else about your child that we should be aware of regarding this trip? Please enter valid data.
- Nonrefundable Deposit Fee50.0
Participant 2
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Address if different than parent/guardian
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Medications:
  My child is taking medications at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage are as follows:
- Medication Information
- Medication Option: please select one REQUIRED No medication of any type may be given to my child except in life-threatening situation. I hereby grant permission for non-prescription medication to be given to my child if deemed appropriate. Please fill out this field.
- Please list any food, medication, or other allergies for this child. Please enter valid data.
- Date of last tetanus/diptheria immunization REQUIRED Please fill out this field. Please enter valid data.
- Please list any physical limitations this child has that might impact his/her participation in this conference or trip to Valleyfair. Please enter valid data.
- Is child subject to homesickness, emotional reactions to new situations, bedwetting, sleepwalking, fainting or any similar concerns? Please enter valid data.
- Has child recently been exposed to any illnesses or diseases such as chicken pox, mumps, measles, etc? If so, please give date of exposure. Please enter valid data.
- Is there anything else about your child that we should be aware of regarding this trip? Please enter valid data.
- Nonrefundable Deposit Fee50.0
Participant 3
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Address if different than parent/guardian
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Medications:
  My child is taking medications at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage are as follows:
- Medication Information
- Medication Option: please select one REQUIRED No medication of any type may be given to my child except in life-threatening situation. I hereby grant permission for non-prescription medication to be given to my child if deemed appropriate. Please fill out this field.
- Please list any food, medication, or other allergies for this child. Please enter valid data.
- Date of last tetanus/diptheria immunization REQUIRED Please fill out this field. Please enter valid data.
- Please list any physical limitations this child has that might impact his/her participation in this conference or trip to Valleyfair. Please enter valid data.
- Is child subject to homesickness, emotional reactions to new situations, bedwetting, sleepwalking, fainting or any similar concerns? Please enter valid data.
- Has child recently been exposed to any illnesses or diseases such as chicken pox, mumps, measles, etc? If so, please give date of exposure. Please enter valid data.
- Is there anything else about your child that we should be aware of regarding this trip? Please enter valid data.
- Nonrefundable Deposit Fee50.0
Participant 4
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Address if different than parent/guardian
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Medications:
  My child is taking medications at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage are as follows:
- Medication Information
- Medication Option: please select one REQUIRED No medication of any type may be given to my child except in life-threatening situation. I hereby grant permission for non-prescription medication to be given to my child if deemed appropriate. Please fill out this field.
- Please list any food, medication, or other allergies for this child. Please enter valid data.
- Date of last tetanus/diptheria immunization REQUIRED Please fill out this field. Please enter valid data.
- Please list any physical limitations this child has that might impact his/her participation in this conference or trip to Valleyfair. Please enter valid data.
- Is child subject to homesickness, emotional reactions to new situations, bedwetting, sleepwalking, fainting or any similar concerns? Please enter valid data.
- Has child recently been exposed to any illnesses or diseases such as chicken pox, mumps, measles, etc? If so, please give date of exposure. Please enter valid data.
- Is there anything else about your child that we should be aware of regarding this trip? Please enter valid data.
- Nonrefundable Deposit Fee50.0

Fee Payment Agreement:
If there is not enough to cover the balance of the fee from fundraising, then I agree to pay the rest of the fee for attending the Steubenville Conference with Divine Mercy Parish and the cost of the ticket to Valleyfair for each participant that I am registering.

I Agree Please select this field.

Permission Waiver Agreement:
I grant permission for this child(ren) to pariticipate in the parish sponsored event that requires transportation to a location away from the parish site. This activity will take place under the guidance and direction of clergy, and/or staff, and/or volunteers from Divine Mercy Parish.

As the parent/legal guardian, I remain legally responsible for any personal actions taken by the above named minor participant(s).

I agree on behalf of myself, the child(ren)'s other parent, my child(ren) named herein, our heirs, successors, and assigns to hold harmless and blameless Divine Mercy Parish, its officers, employees, volunteers, directors and agents; the Diocese of Sioux City, it's employees, agents, chaperones, and volunteers; or representative associated with the event for the reasonable attorney's fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from negligence of the parish or diocese.

I Agree Please select this field.

Please type your name to indicate your agreement of the above Fee Payment Agreement and Permission Waiver Agreement statements. Please enter valid data.

Doctor or Clinic to contact in case of emergency REQUIRED Please fill out this field. Please enter valid data.

Doctor or Clinic Phone Number REQUIRED Please fill out this field. Please enter valid data.

Emergency Medical Treatment:
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. Please contact me immediately, but if you cannot, please contact the family doctor named below.

Non-Emergency Medical Treatment:
In the event that my child presents symptoms of illness such as (but not limited to) fever, diarrhea, vomiting, I wish to be notified immediately.

Please type in your name below to indicate agreement with the above Emergency and Non-Emergency Medical Treatment statements above. REQUIRED Please fill out this field. Please enter valid data.

Please be sure to send along proof of health insurance with your child in the case of emergency medical treatment.

Divine Mercy Catholic Parish

of North Central Iowa

Steubenville 2024 Registration

Information about Divine Mercy plans for Steubenville 2024