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2019 Vacation Bible School
Monday June 24 -June 28, 2019
9am to Noon at Our lady of Grace

Registration is required for participation in our Summer Vacation Bible School.  It is mandatory for us to have the child’s contact information, health concerns, and signed waivers on file for you to leave your child in our care.  Each child must be registered separately.

Registration Donations Suggestions: $10 for 1 child, $20 for 2 children, $25 for 3 or more children. 

Payments can be made by cash or check through: the mail, the parish welcome center (For OLG only), or  the parish office. 

All checks should be made payable to Our Lady of Grace Church. 

REGISTRATION DEADLINE: MAY 26, 2019
 

We, the parents/guardians do hereby give our permission for him/her to attend Vacation Bible School 2019 at Our Lady of Grace Church. 

We do hereby release and forever discharge the Diocese of Greensburg and designated chaperones from any/all actions or suits in law or equity which we might hereafter have by reasons of injuries sustained by our son/daughter participating in the above mentioned activity. 

PHOTOGRAPHIC RELEASE LETTER

I hereby grant to the Diocese of Greensburg, Pennsylvania, and its respective licensees, successors and assigns, the right and permission, with respect to those photographs taken of me or the minor named below on whose behalf I am signing, and with respect to any printed or electronic matter in connection therewith, to do the following: To include such photographs on the Diocese of Greensburg website and on print material (names of minors are not used for web or print media/publications without prior consent)

I hereby release, discharge and agree to indemnify and hold harmless the Diocese of Greensburg and its legal representatives, licensees, successor and assigns, from all claims and demands whatsoever arising out of or in connection with the foregoing, and waive any right to inspect or approve the same.

I hereby certify that I am the parent and/or guardian of a minor under the age of eighteen years, and hereby consent on behalf of said minor to the use of any of the photographs taken of said minor pursuant to the terms set forth in this Photographic Release, including, without limitation, the release, discharge and hold harmless provisions thereof.

Date: May 21, 2019

Please select who will be participating...
Minor
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First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Grade child (Teen Helper) is entering in Fall 2019 *
Teen Helper
PK (4yrs old)
K
1
2
3
4
5
At what parish are you registered?*
Our Lady of Grace
St. Benedict
Other

If other, what is your parish of registration?
My child has a food allergy*
No
Yes

If answered yes to food allergy, please list the allergies
My child has a learning disability*
No
Yes

If answered yes to learning disability, please list ALL learning disabilities
My child has a medical condition*
No
Yes

If answered yes to medical condition, please list ALL medical conditions

Please list any special accommodations that your child may need
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Father/Primary Guardian Information

First Name

Last Name

Address (if different from Participant)

Email

Home Phone (if different from participant)

Cell Phone
Mother/Primary Guardian Information

First Name

Last Name

Address (if different from Participant)

Email

Home Phone (if different from Participant)

Cell Phone
Custody/Divorce/Separation Situations

Are there any concerns/situations that we should be aware of pertaining to the safety/security of this child?

Is there anyone who is NOT permitted to be with your child?
Are you interested in helping? (includes Teens)
I would like to.....(please check all that apply)
Be a crew leader (lesson leader)
Be a crew helper (help in the room, does not present the lesson)
staff the sign-in table
prepare lesson supplies at home (ie. cut out crafts)
decorating
games team
imagination station leader
PK/K Groups
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Grade child (Teen Helper) is entering in Fall 2019 *
Teen Helper
PK (4yrs old)
K
1
2
3
4
5
At what parish are you registered?*
Our Lady of Grace
St. Benedict
Other

If other, what is your parish of registration?
My child has a food allergy*
No
Yes

If answered yes to food allergy, please list the allergies
My child has a learning disability*
No
Yes

If answered yes to learning disability, please list ALL learning disabilities
My child has a medical condition*
No
Yes

If answered yes to medical condition, please list ALL medical conditions

Please list any special accommodations that your child may need
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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