Would You Like to Help with VBS Or Totus Tuus?

Youth Volunteers Needed!

Are you in Middle School or High School?

Would you like to help with VBS or Totus Tuus?

Youth Volunteers are needed to assist

with Vacation Bible School and with Totus Tuus.

TotusTuusJune 20th - 24th, 2016 (Monday-Thursday: 9am-2:30pm, Friday: 9am-12pm)
Vacation Bible School (9:00-12:00pm)June 20th- 23rd, 2016 – 4 DAYS ONLY

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Name______Grade______(in 2016-2017)

______I could help with Vacation Bible School from 8:30 a.m. to 12:15p.m.,June 20th-23rd

______I could help with Totus Tuus from June 20th-24th, Monday-Thursday: 8:30 a.m. to 2:30 p.m.,

Friday: 8:30 a.m. to 12:00 p.m.

______I could help where I am most needed

Please return this form with the completed Parental/Guardian Consent Form and Liability Waiver

To:VBS/Totus Tuus, Catholic Formation Office, 605 Plymouth St. N.E., Le Mars IA 51031 by June 1, 2016.

Patti UhalPhone
______

Parental/Guardian Consent Form and Liability Waiver

Parent/Guardian’s name(s) ______Parish______

Home address Street City State Zip Landline phone

Family email (only if checked regularly)______

Father cell phone: Father work phone:

Mother cell phone: Mother work phone:

I agree on behalf of myself, my child(ren) named herein, or our heirs, successors, and assigns, to hold harmless and defend the parishes of the Le Mars Area Cluster (St. Jamesand St. Joseph parishes in Le Mars,and Akron), Gehlen Catholic Schools, Religious Education Program of the Le Mars Area, their officers, directors, employees and agents, and the Diocese of Sioux City, its employees, and agents and chaperones, or representative 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 cluster parishes, Gehlen Catholic Schools, and the Religious Education Program of the Le Mars Area their officers, directors and agents, and the Diocese of Sioux City, its employees and agents and chaperones, or representative 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 negligence of the cluster, school, or diocese.

Signature______Date______

_____ (Please Initial) Photo Release: Pictures of my child taken during the event may be used in print or electronic media for the purposes of publicity for future events, unless I indicate to the Diocesan Director of Religious Education in writing to the contrary.

(over)

MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. (Of the following statements pertaining to medical matters, sign only those that are applicable.)

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:

#1 Contact Name & Relationship ______Phone(s) Home______Cell______

#2 Contact Name & Relationship ______Phone(s) Home______Cell______

Family Doctor______Phone______

Family Health Plan Carrier______Policy #______

Other Medical Treatment: In the event it comes to the attention of the cluster, parish, its officers, directors and agents, and the Diocese of Sioux City, chaperones, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reversed to myself).

Signature:______Date:______

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Students are not to have medications on their person. Students need to bring medications to the TotusTuus/VBS office for safekeeping. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage, are as follows:______

Signature______Date______

No medication of any type whether prescription or non-prescription, may be administered to my child unless the situation is life-threatening and emergency treatment is required.

Signature______Date______

OR:

I hereby grant permission for non-prescription medication (such as non-aspirin products, i.e. acetaminophen or ibuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.

Signature______Date______

Specific Medical Information: The parish/school will take reasonable care to see the following information will be held in confidence.

Allergic reactions (medications, foods, plants, insects, etc.) ______Please use

______additional pages

Does your child have a medically prescribed diet?______if needed for

______information for

Any physical limitations?______more than one

______child.

Has child recently been exposed to contagious disease or conditions such as mumps, measles, Chicken pox, etc.? If so, list date and disease or condition______

You should be aware of these special medical conditions of my child: ______