Mass Schedule: Saturday 6 p.m. | Sunday 10:30 a.m.
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Skiing/Tubing Registration & Consent - Youth
Financial aid is available for youth activities. Please contact Laura Hollinrake, DRE, at (641) 828-7050 Ext. 2.
Father's Name
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First
Last
Mother's Name
*
First
Last
Father's Address
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Line 1
Line 2
City
State
Zip Code
Country
Mother's Address
*
Line 1
Line 2
City
State
Zip Code
Country
If father and mother live at the same address, you may type "same" in fields for Mother's Address."
Father's Home Phone
*
Father's Cell
*
Father's Cell Phone Service Provider
*
Please provide this so Laura can communicate via email to text for updates regarding Faith Formation.
Father's Email
*
Mother's Home Phone
*
Mother's Cell
*
Mother's Cell Phone Service Provider
*
Please provide this so Laura can communicate via email to text for updates regarding Faith Formation.
Mother's Email
*
*
Indicates required field
Primary Contact Person:
*
Father
Mother
Both
Emergency Contact Name
*
First
Last
Emergency Contact Phone
*
Name of Medical Insurance Company
*
Name of Policy Holder
*
Policy/Group Number
*
Child's Name
*
First
Last
Child's Grade
*
Child's Birth Date
*
Child's Special Needs/Health Concerns/Allergies
*
Child #2 Name
*
First
Last
Child #2 Grade
*
Child #2 Birth Date
*
Child #2 Special Needs/Health Concerns/Allergies
*
Child #3 Name
*
First
Last
Child #3 Grade
*
Child #3 Birth Date
*
Child #3 Special Needs/Health Concerns/Allergies
*
Authorization for Use of Name(s), Likeness(es), and/or Photographic Image(s)
*
Yes
No
I grant permission to St. Anthony Catholic Church to use my child's/children's name(s), likeness(es), and/or photographic image(s) in the production of parish and/or diocesan newsletters, bulletins, websites, posters, bulletin boards, slide shows and other parish or diocesan promotional materials and in articles about the parish that may be published in local or diocesan newspapers. I further understand that St. Anthony Catholic Church is not responsible for access to the Internet information or downloads made by users using the web prior to removal of web references and that my child’s/children's name(s), likeness(es) or image(s) may be used in any publication already printed or published prior to removal by St. Anthony Catholic Church.
Statement of Consent & Liability Release
*
I give permission for my child/legal dependent to be transported to and to participate in the above mentioned activity, coordinated by
St. Anthony Catholic Church. In
the event of sickness or accident, the adult(s) supervising this activity have my permission to secure medical care for my child/legal dependent.
I hereby release St. Anthony Catholic Church,
its employees and volunteers,
and any affiliated deanery or diocesan employees and volunteers
from any and all claims arising out of or from any accident or other occurrence, causing injury to any person or property, during this event. If my child/children become(s) injured or ill and I cannot be reach
ed, I authorize for my child/children all surgical, x-ray, laboratory, anesthesia, and/or other medical procedures as may be performed or prescribed by the attending physician and/or emergency personnel. I accept responsibility for all medical/surgical treatment charges, which may be incurred.
Please note, by typing your name and date below you are providing your electronic signature for this "Statement of Consent & Liability Release."
Parent Signature
*
By typing your name in this line you are providing your electronic signature for the "Liability Release."
Date
*
Submit