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High School/Middle School Permission Form for Volunteering at Monumental - Celebrating God's Greatness VBS

We are excited for Immaculate Conception/St Patrick & St. Anne Catholic Churches to partner together for Monumental - Celebrating God's Greatness Vacation Bible School!

Our volunteers are what make VBS a smashing success!

Date: July 25 - 29, 2022

Time: 8:45 - Noon each day (*Note: Friday will end at 12:30 pm)

Location: St. Anne Catholic School - 140 Church Hill Road - Somerset, WI 54025

What parish are you associated with (Immaculate Conception/St Patrick, St. Anne, or Other)? If other, please name.*

Answer Required

List allergies/medical concerns/special needs and please be specific about necessary treatment we may need to utilize

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First Name*

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Last Name*

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First Name

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Last Name

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First Name

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Last Name

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Parent/Legal Guardian #1 First Name*

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Parent/Legal Guardian #1 Last Name*

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Street Address*

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City*

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Zip/Postal*

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Email Address*

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Primary Day Telephone Number*

*10 digit phone number with no special characters or spaces added

Number Required

Secondary Telephone Number

*10 digit phone number with no special characters or spaces added

Number Required

Parent/Legal Guardian #2 First Name

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Parent/Legal Guardian #2 Last Name

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Street Address

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City

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Zip/Postal

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Email Address

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Primary Day Telephone Number

*10 digit phone number with no special characters or spaces added

Number Required

Secondary Telephone Number

*10 digit phone number with no special characters or spaces added

Number Required

Please respond to this next section for all children that are volunteering from your family. Thank you!

Emergency Contact First and Last Name*

In case of an emergency, illness, or behavior problems, we will contact the parent/legal guardian first. If neither are reachable, please name someone who we can contact in case of emergency, illness, or behavioral issues.

Answer Required

Emergency Phone Number*

*10 digit phone number with no special characters or spaces added

Number Required

Relationship*

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Emergency Hospital Name*

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Emergency Hospital Phone Number*

*10 digit phone number with no special characters or spaces added

Number Required

Family Physician*

Answer Required

Medical Clinic Name*

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Medical Clinic Phone Number*

*10 digit phone number with no special characters or spaces added

Number Required

Dentist Name*

Answer Required

Dentist Phone Number*

*10 digit phone number with no special characters or spaces added

Number Required

Eye Doctor

Answer Required

Eye Doctor Phone Number

*10 digit phone number with no special characters or spaces added

Number Required

I hereby authorize the healthcare provider or designated person to contact the above listed physician in case of an emergency and parent/legal guardian cannot be reached.*

Answer Required

Yes

I hereby give permission to chaperones of St. Anne Catholic Church and Immaculate Conception/St Patrick Catholic Church to distribute non-prescription/over-the-counter medications and treatments to my child/ward such as but not limited to: applying bandages, first-aid ointments or sprays, ice/heat compresses, dispensing of non-aspirin pain relievers, cough drops, syrups, and antacids and the like.*

Answer Required

Yes

In the event of illness or injury and I am unable to be reached, I do hereby consent to whatever examination, x-ray, anesthetic, medical, surgical, dental diagnosis or treatment and hospital care considered necessary in the best judgement of the attending physician, surgeon, or dentist and performed by or under the supervision of the medical staff of the hospital or facility furnishing medical or dental services. *

Answer Required

Yes

I give permission for my child(ren) to participate in Monumental - Celebrating God's Greatness Vacation Bible School being hosted by Immaculate Conception/St Patrick Church and St. Anne Catholic Church. By checking "yes" in the box below, I am saying "yes" to this statement and, I understand the risks and hazards associated with the event, including injury, illness, and the rare possibility of death. I understand that I may discuss any concerns or questions I have about this event with a representative of St. Anne Catholic Church or Immaculate Conception/St Patrick Catholic Church or the Diocese of Superior prior to giving permission for my child(ren) to participate. In consideration for my child(ren)'s participation, I agree to reimburse and indemnify St. Anne Catholic Church and/or Immaculate Conception/St Patrick Catholic Church and the Diocese of Superior for all reasonable legal and court fees incurred by the parishes/diocese in defending a lawsuit that I or my child/ren may bring against the parishes/diocese which relates to Monumental - Celebrating God's Greatness VBS if the parishes/diocese is found not legally liable by the courts and prevails in the lawsuit. If the parish/diocese is found legally liable for any injuries sustained by my child(ren), this paragraph will not apply. I further agree to reimburse the diocese or any other agency for property damage or any bodily harm to other participants caused by my child/ren.*

Answer Required

Yes

Image & Likeness Release. I give Immaculate Conception/St. Patrick and St. Anne parishes permission to use any image of my child in both print and electronic publicity. The videotape, photograph, slide, audiotape, or any other visual or audio reproduction in which my child may appear may include promotional activities such as, but not limited to, websites, social media sites, newsprint, flyers, or brochures. Immaculate Conception/St Patrick & St. Anne parishes reserve the rights to determine which image and likeness is used and how long it will remain on the site or is used in media materials.*

Answer Required

The electronic signature below reflects the person who completed this online registration/permission form.*

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