St. Elizabeth Ann Seton Church

REGISTRATION FORM – 6th & 7th Graders

St. Elizabeth Ann Seton Church

Vacation Bible School

VBS will be held June 25-June 29 2012 from 9:30 AM-12:30 PM [8:45 AM -12:30 PM on Wed.]. There is no charge for 6th & 7th graders, who will be helping with the camp service project. If you have any questions, please feel free to contact either Marissa Sias at or (908) 237-0133 or Marian Wasitowski at or (609)333-9985

_______________________________________________________________________________________Child’s Last Name First Name Daytime Telephone Number

_______________________________________________________________________________________Grade entering in Sept.12 Date of Birth

_______________________________________________________________________________________Street Address Apt. # or P.O. Box #

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Town State Zip Code

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Name and Telephone Number of Drop Off / Pick-Up Person

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Emergency Contact Person Relationship to Child Telephone Number

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Physician’s Name Telephone Number

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Allergies (especially food allergies):

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Other Helpful Information (illnesses, medications, activity restrictions, etc.):

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Emergency Medical Treatment Authorization:

I request that my son/daughter participate in the above-described activity. Should emergency medical treatment be necessary and I am unable to be contacted immediately, I authorize the delegated agents of the above-named church to act on my behalf and approve appropriate treatment. I specifically waive claim or claims that may be derived from any accident or injury sustained by my son/daughter en route and during the activity. I further agree to indemnify and save harmless the above-named church, the Catholic Diocese of Metuchen, their staff, and all adult supervisors working on their behalf. I further understand that parish representatives are NOT permitted to dispense medication. I also agree to allow my child’s picture to be used for publicity or educational purposes, including use on the parish website.

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Parent/Guardian Last Name First Name Daytime Telephone Number

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Parent/Guardian Signature Date

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Parent email address