Registration Ski/Tubing - Youth - St. Anthony Knoxville

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 *

First

Last

Mother's Name *

First

Last

Father's Address *

Line 1

Line 2

City

State

Zip Code

Country

Mother's Address *

Line 1

Line 2

City

State

Zip Code

Country

Father's Home Phone *

Father's Cell *

Father's Cell Phone Service Provider *

Father's Email *

Mother's Home Phone *

Mother's Cell *

Mother's Cell Phone Service Provider *

Mother's Email *

* Indicates required field

Primary Contact Person: *

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 reached, 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 *

Date *

Submit