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Participant Registration

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Registro en Español

St. Gertrude's Mora

Location

8 CR A033

Mora, NM 87732

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Contact Mary-Catherine Sandoval:

505-449-7319

mc09sandoval@gmail.com

First, Tell Us About Yourself:

Parent Information

Please note that by typing/signing your name on the lines following some of the fields in this form, you are agreeing to the terms outlined in this form. This will be accepted as your electronic signature.

First Name

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Last Name

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Address 1

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Address 2

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City

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State/Province

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ZIP/Postal Code

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Country

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Contact Phone 1

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Contact Phone 2

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Parent 2 First & Last Name

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Parent 2 Phone Number

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Emergency Contact Name

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Emergency Contact Relationship

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Emergency Contact Phone

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Photo/Publicity Release Form St. Gertrude the Great Church may have opportunities to publicize and promote its Vacation Bible School program to church members and to the public. In such case, photos, but no names, would be used. I give St. Gertrude the Great Church permission to include my above-named child, in publicity and promotional materials.

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By typing my name in this box I agree to the terms: Release Form As the parent/guardian of the child names in this form I agree to release St. Gertrude the Great Church, its successors, and assigns from all claims of loss, damage, or injury sustained by the participation of Vacation Bible School, whether caused by the negligence of the church, its agents, employees or otherwise. I further agree to indemnity said church, its successors, and assigns against any and all claims for such loss, damage, or injury sustained by the participation, whether caused by the negligence of the church or its officers, agents, employees or otherwise.

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By typing my name in this box I agree to the terms: Permission to Provide Medical Attention: I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. If I cannot be reached, I authorize St. Gertrude the Great Church to transport my child to the nearest care facility or to the facility I specify on this form. I also authorize the performance of medical, minor surgical, or diagnostic procedures, including the administration of local anesthesia that may be deemed necessary or advisable by the attending physician or surgeon in the diagnosis and emergency treatment of my child in the event that I cannot be reached for direct authorization.

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Specify the Medical Hospital/Facility you'd prefer your child be sent to in the case of medical emergency.

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By typing my name in this box I agree to the terms: ST. GERTRUDE THE GREAT CATHOLIC CHURCH PERMISSION SLIP-MEDICAL AUTHORIZATION-INDEMNITY AGREEMENT: I remain legally responsible for any personal actions taken by my child. I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend ST. GERTRUDE THE GREAT PARISH its officers, directors, employees and agents, and the Saint Gertrude the Great Parish and the Archdiocese of Santa Fe, its employees and agents, chaperones, or representatives associated with the event, from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish/school, its officers, directors and agents, and the Archdiocese of Santa Fe, its employees and agents and chaperones, or representatives associated with the event for reasonable attorney's fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/school or the Archdiocese of Santa Fe. I hereby authorize the Supervisor of the activity or his/her designee to act in my behalf to authorize such medical attention, surgery, or other health care services, as may be recommended in an emergency situation while participating in the activity. If the below names physician cannot be reached, I hereby authorize any licensed physician or medical center to treat my child.

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Name of Physician

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Phone Number of Physician

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I hereby authorize the Supervisor of the activity or his/her designee to administer the following medication to my child according to the instructions described here: (MUST PROVIDE MEDICATION NAME & DIRECTIONS) - If the medication is prescribed by a doctor, the prescription in its original container will be provided to the Supervisor of the activity:

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Click here for your FREE Friends With God Kids Activity Pack

By checking the box you will be emailed your Free Friends With God Kids Activity Pack.

You are also agreeing to receive emails about family resources from Lifetree. You can unsubscribe at any time. We value your privacy. Your information will not be shared with a third party. Lifetree is a division of Group Publishing, the creators of Group VBS and other faith-building resources. Click to learn more about Lifetree.

Tell Us About Your Participant

First Name

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Last Name

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Current Grade

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Gender

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Date Of Birth

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Shirt Size

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Allergies

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Medical Concerns

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Do you have friends you would like to be placed with? We will do our best to group selected friends together in the same crew, but we cannot promise all requests will be possible.

Friend 1 First Name

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Friend 1 Last Name

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Friend 2 First Name

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Friend 2 Last Name

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Friend 3 First Name

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Friend 3 Last Name

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Comments

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