Vacation Bible School Registration -- for VBS at St Cecelia

Parent 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 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 Maximum 20 characters Please fill out this field. Please enter a phone number.

Parent 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.
Email REQUIRED Please fill out this field. Please enter an email address.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.

Who will pick your child(ren) up from VBS? REQUIRED Please fill out this field. Please enter valid data.

I/We, the parent(s)/guardian(s) of the children named below, authorize and give full consent, without limitation or reservation, to Divine Mercy Parish, and the Diocese of Sioux City to publish any photograph or video in which the below named student appears while participating in any program associated with Divine Mercy Parish ministry. There will be no compensation for use of any photograph or video at the time of publication or in the future.

I agree with the photograph and video consent statement given (above). REQUIRED I agree I disagree Please fill out this field.

Consent and Liability Waiver

I, the undersigned parent or guardian, agree to the following. As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above-named minor(s) "participants". I agree on behalf of myself, my child(ren), and my spouse, that the Diocese of Sioux City, chaperones, and representatives associated with the event(s), (referred collectively as "them"): We release and forever discharge them from any and all claims and causes of action that we may have against them, arising in connection with the activities of the participating child(ren) while attending an event or in connection with any illness or injury or cost of medical treatment therewith, in so much as they have made reasonable efforts to maintain the safety of my child(ren) while in their care and my child(ren) has/have complied with all rules and instructions of the program.

Consent and Liability Waver (above) REQUIRED I agree. I do not agree. Please fill out this field.

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. REQUIRED I agree. I do not agree Please fill out this field.

I hereby warrant that to the best of my knowledge, my child(ren) is/are in good health, and I assume all responsibility for the health of my child(ren). I have reviewed and completely and accurately completed this medical information. It will be assumed in the event it comes to the attention of the Parish or Parish representative/director and/or volunteer that should my child(ren) become ill or injured I will be called.

Children's Health Statement (above) REQUIRED I agree. Please fill out this field.

Emergency Contact Name: (other than parents listed above) REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact Phone Number REQUIRED Please fill out this field. Please enter valid data.

Number of children registering for vacation bible school REQUIRED Please fill out this field.
Child 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.
- Age of child REQUIRED Please fill out this field. Please enter an integer (number).
- For school grade, if your child will be entering preschool, please select 0. Thank you!
- 25-26 School year grade REQUIRED Please fill out this field.
- Sex REQUIRED Male Female Please fill out this field.
- In the following box, please list any special restrictions, physical limitations, medical conditions, or food allergies & intolerances.
- Medical conditions, allergies, restrictions, etc.
Child 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.
- Age of child REQUIRED Please fill out this field. Please enter an integer (number).
- For school grade, if your child will be entering preschool, please select 0. Thank you!
- 25-26 School year grade REQUIRED Please fill out this field.
- Sex REQUIRED Male Female Please fill out this field.
- In the following box, please list any special restrictions, physical limitations, medical conditions, or food allergies & intolerances.
- Medical conditions, allergies, restrictions, etc.
Child 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.
- Age of child REQUIRED Please fill out this field. Please enter an integer (number).
- For school grade, if your child will be entering preschool, please select 0. Thank you!
- 25-26 School year grade REQUIRED Please fill out this field.
- Sex REQUIRED Male Female Please fill out this field.
- In the following box, please list any special restrictions, physical limitations, medical conditions, or food allergies & intolerances.
- Medical conditions, allergies, restrictions, etc.
Child 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.
- Age of child REQUIRED Please fill out this field. Please enter an integer (number).
- For school grade, if your child will be entering preschool, please select 0. Thank you!
- 25-26 School year grade REQUIRED Please fill out this field.
- Sex REQUIRED Male Female Please fill out this field.
- In the following box, please list any special restrictions, physical limitations, medical conditions, or food allergies & intolerances.
- Medical conditions, allergies, restrictions, etc.
Child 5
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Age of child REQUIRED Please fill out this field. Please enter an integer (number).
- For school grade, if your child will be entering preschool, please select 0. Thank you!
- 25-26 School year grade REQUIRED Please fill out this field.
- Sex REQUIRED Male Female Please fill out this field.
- In the following box, please list any special restrictions, physical limitations, medical conditions, or food allergies & intolerances.
- Medical conditions, allergies, restrictions, etc.
Child 6
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Age of child REQUIRED Please fill out this field. Please enter an integer (number).
- For school grade, if your child will be entering preschool, please select 0. Thank you!
- 25-26 School year grade REQUIRED Please fill out this field.
- Sex REQUIRED Male Female Please fill out this field.
- In the following box, please list any special restrictions, physical limitations, medical conditions, or food allergies & intolerances.
- Medical conditions, allergies, restrictions, etc.
Child 7
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Age of child REQUIRED Please fill out this field. Please enter an integer (number).
- For school grade, if your child will be entering preschool, please select 0. Thank you!
- 25-26 School year grade REQUIRED Please fill out this field.
- Sex REQUIRED Male Female Please fill out this field.
- In the following box, please list any special restrictions, physical limitations, medical conditions, or food allergies & intolerances.
- Medical conditions, allergies, restrictions, etc.
Child 8
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Age of child REQUIRED Please fill out this field. Please enter an integer (number).
- For school grade, if your child will be entering preschool, please select 0. Thank you!
- 25-26 School year grade REQUIRED Please fill out this field.
- Sex REQUIRED Male Female Please fill out this field.
- In the following box, please list any special restrictions, physical limitations, medical conditions, or food allergies & intolerances.
- Medical conditions, allergies, restrictions, etc.
Child 9
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Age of child REQUIRED Please fill out this field. Please enter an integer (number).
- For school grade, if your child will be entering preschool, please select 0. Thank you!
- 25-26 School year grade REQUIRED Please fill out this field.
- Sex REQUIRED Male Female Please fill out this field.
- In the following box, please list any special restrictions, physical limitations, medical conditions, or food allergies & intolerances.
- Medical conditions, allergies, restrictions, etc.
Child 10
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Age of child REQUIRED Please fill out this field. Please enter an integer (number).
- For school grade, if your child will be entering preschool, please select 0. Thank you!
- 25-26 School year grade REQUIRED Please fill out this field.
- Sex REQUIRED Male Female Please fill out this field.
- In the following box, please list any special restrictions, physical limitations, medical conditions, or food allergies & intolerances.
- Medical conditions, allergies, restrictions, etc.

Donation to help support VBS! Registration is free -- always! However, we are very thankful for all donations for our VBS program. $ Please enter a positive decimal.

If you do not wish to donate at this time, please enter $0.00 and hit 'Proceed to Payment' to submit your registration form.

Divine Mercy Catholic Parish

of North Central Iowa

Vacation Bible School Registration -- for VBS at St Cecelia

Vacation Bible School Details: