Edge Retreat 2020

Made Known

Child's Information
Name
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Sex
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Age
Grade for 2019/2020 School Year
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Address
T-shirt size
Family Information
Parent/Guardian Name #1
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Phone --
Phone --
E-mail
Parent/Guardian Name #2
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Phone --
Phone --
E-mail
Alternate Pickup
Name
  •  
Phone --
I understand that reasonable precautions will be taken to safeguard the health and well being of the participants in this VBS and that I will be notified as soon as possible in the event of an emergency. In the case of sickness or an accident, I authorize and consent the VBS Team, or other associated volunteers of the VBS program to obtain medical care from a licensed physician, hospital, or medical clinic for my son/daughter in the event that myself or other legal guardian(s) cannot be reached. I hereby do release and forever discharge this Diocese, and Parish from all manners of actions, claims which I or the child named above shall or may have for any reason, arising during my child’s attendance of the VBS. Unless other written instruction is submitted, I also consent to allowing my child’s image to be recorded, either by photograph or video, and used during the VBS week or for future advertisement of Parish VBS programs. Any other use will require your further consent.
Parent/Guardian Signature
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Today's Date //
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HEALTH INFORMATION
ALL INFORMATION WILL BE HELD IN STRICT CONFIDENCE
I hereby warrant to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. Of the following statements pertaining to medical matters, sign only those in accordance with your wishes:
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.
In the event of an emergency and you are unable to reach me, contact:
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Relationship
Phone --
Family Doctor
Phone --
Medications My child will bring all such medications, well labeled, that are necessary. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency are as follows:
Medication(s), Dosage(s), and Administration:
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*
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Today's Date //
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My son/daughter has had an episode of the following:
Allergic reactions to the following (foods, dyes, latex, etc.)
Has had a medical surgery within the last six months?
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Still under doctor's care?
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Has a medically prescribed diet?
The following physical limitations?
Immunizations current and up to date?
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You should also be aware of these special medical conditions of my child:
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I fully understand the foregoing statements and sign this Parental/Guardian Medical Consent Waiver knowingly, freely, and willingly.
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Today's Date //
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Insurance Information
Insurance Carrier
Name of Insured:
Insurance Policy Number
-
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Payment Information
Registration Fee  
Quantity Extended

First Child | $35.00

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Order Summary
Subtotal
Discount
Sales Tax
Shipping & Handling
Total

Payment Type
  •  

 
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