Paducah Catholic Community

Vacation Bible School 2016 Registration Form

“JESUS IS OUR GOOD SHEPHERD”

For Preschool (age 4 and potty trained) through 6th Grade

June 6-10 9 am - 12:15 pm St. Mary Elementary School

Registration Fee: $20 per child for the first 2 children. Each additional child is $5.00. Register and pay by May 11th. The cost after May 11th increases to $25 per child for the first two children, and $7.50 for each additional child. Make check payable to Paducah Faith Formation. Contact Ging Smith at 270 4430295 if financial assistance is needed. Mail this form and payment to: VBS Paducah Faith Formation 377 Highland Blvd., Paducah KY 42003.

Parent’s/ Guardian’s Name ______

Home Phone______Cell Phone ______

Address ______

Email Address (print clearly)______

Parish ______

*T-Shirt Size (KS:Kids Small; KM:Kids Medium; KL:Kids Large, AS:Adults Small, AM: Adults Medium,

AL: Adults Large)

______I would be interested in being an adult volunteer during VBS.

You are required to complete the Diocesan Form A (front and back)

for each child attending Vacation Bible School.

It is attached for your convenience.

FORM A (pg. 1 of 2)

ROMAN CATHOLIC DIOCESE OF OWENSBORO,600 Locust St., Owensboro, KY 42301

Name/Address ofInstitution(Parish,School,etc.)SponsoringActivity: PADUCAH CATHOLIC COMMUNITY VBS 377 HIGHLAND BLVD,, PADUCAH KY 42003

EMERGENCY MEDICAL RELEASE AND HEALTH INFORMATION FOR MINORS

MinorParticipant'sName ______Male / Female(circle) Birthdate/__/Address Phone

Father's ___orLegal Guardian's_

HomeAddress

HomePhone______

Work/CellPhone------

Mother's ___orLegalGuardian's_Name------

HomePhone ______

HomeAddress___

Work/CeIIPhone__

Inanemergency,pleasenotify(Name/Phone#):______

Name of Individual In Case Parent/Guardian Cannot Be Reached: ______Phone: ______

Isanyonedesignatedastheprimaryorsolecustodialparentbycourtorderordecree?NAME______

Name anyone who is restrained from picking up the child: ______

HEALTH HISTORY:

Child'sPhysician:_

Any pre-existing or present medical conditions, disabilities, physical handicaps,or major illnesses:.



Nameofanyprescriptionmedicationsandconcisedirections,includingdosageandfrequencyofdosage:

______




Ifmychildisinpainandif deemedadvisablebyasupervisoryadult, I grantpermissionforthefollowingnon-prescription

medicationtobegiven:Acetaminophen__Yes

Ibuprofen_____ Yes

No

No

Anyallergies(food,latex,animals,etc?)Yes/No ______Allergic to anymedications? Yes/No______

Ifyes,explain: ______

Dateoflasttetanusshot_____Contactlenses?Yes/No______

Anyswimmingrestrictions:Yes_____NoWhat?______



Anyactivityrestrictions?__Yes_____NoWhat?------

(OVER)

Revised October 2012

FORM A (pg. 2 of 2)

EMERGENCY MEDICAL RELEASE AND HEALTH INFORMATION FOR MINORS (cont'd.)

Consent forEmergency Care

I/We, the undersignedparent(s)/guardianof ______doherebyrequestandgivepermissionfortheprovision of necessary medical treatment for the above-named child. I/we understand that supervisory personnel will immediately seek to reach the above-named child's contact(s) in case of a medical emergency. If any injury/incident does occur during this event that requires transportation to a hospital or doctor, I/we give permission for a representative of the parish/school/etc. to secure necessary medical attention. I/we further authorize any duly qualified physician, dentist, or hospital to render such aid or treatment that may be necessary and understand that I/we assume responsibility for the cost of any such treatment. I/we authorize the release of pertinent medical information to supervisorypersonnel.

*Please understand that, depending upon the seriousness of the situation, your child may be transported to thenearest hospital.

Parent/GuardianSignature: ______Date:_

Witness to Signature: ______Date:

HealthInsuranceCompany(thatcoversabove-namedchild):__

Insurance Policy #______Group #______

PERMISSION FORM LIABILITY RELEASE

PURPOSE: This Permission Form/Liability Release is intended to cover all diocesan-, deanery-, parish-, and Catholic school­ sponsored activities for anyone under the age of eighteen (18). Catholic schools and/or programs have the right to require parent/guardian to give permission for students/participants eighteen (18) years of age or older.

I/We, the parent(s) and/or legalguardian(s)of ______(child's name),herebyrequestpermissionforthischildtoparticipateinanyandalloftheactivities oftheRomanCatholicDioceseofOwensboroand

(nameof organization) I/We release from responsibility anyperson

transportingmy/our child to or from activities. I/We understand the possibility of unforeseen hazards and know the inherent possibility of risk. Taking into account the subject's age, I/we believe that the subject of this release is physically and mentally capable of taking reasonable precautions to protect his/her own safety and has the maturity and judgment not to put himself/herselfor others in dangerous situations.

Iherebyconsenttotheuseofaphotograph ofmychildforthepurposeofpublication. __Yes ______No

Parent/guardian Signature------Date______

Adult witnesstoSignature______Date______

Receivedby------Date ______

(Signature of DRE, CRE, Teacher/School Personnel, Youth Representative, etc.)

IF THERE ARE ANY CHANGES IN THE INFORMATION ON THIS FORM, IT IS YOUR RESPONSIBILITY TO NOTIFY THE APPROPRIATE LEADER AND GET THE FORMUPDATED. (e.g. insurance policy changes, changes in medical condition or medicines, court orders, etc.)

Revised October 2012

Completethisformonlyifyourchild/childrenwillbepickedupbysomeone other than a parent/guardian.

I,(parent/guardian)_ givepermissionforthefollowingadultstopickupmychild/childrenfromVBS.

Adult's Name / Relationship to Child / Adult's Phone Number
Child's Name / Grade

Signed(Parent/Guardian):------

VBS Supply Pick-up

Sunday, June 5 from 2 to 4 pm

•St. Mary Elementary Schoollibrary

•Pick up your classroom assignment, bible verse, etc.

•Eachchildneedstobringa10packCapriSunorKool-AidJammers.

Drop theseoffwhenpickingupsupplies.

•Late registrationsalso taken at this time. (T-shirt will be several days late if registeringlate).

VBS Information

Monday through Friday, June 6-10from 9am to 12:15pm

Daycareavailable 8-9am (Drop off at the Gym)

PLEASEHAVECHILDRENWEARTENNISSHOES EACHDAY. NOFLIP FLOPS ORSANDALS.

****DROP-OFFwillbeintheGym.Wewillhaveopeningprayereachday...

feelfree to joinus.

****PICK-UP : Parents /Guardians must come into the Gym to pick up children at dismissal.

Closing Mass, Friday, June 10 at9:00 am.

ALL ARE INVITED.

DAILY LUNCH MENU

Monday:Hamburgers, sides, milk,juice

Tuesday:Tacos, sides,milk,juice

Wednesday:Hot dogs, sides,milk,juice

Thursday:Chicken nuggets, sides,milk,juice Friday:Pizza and icecream

If you prefer, your child can bring a sack lunch instead.

QUESTIONS: Matt Rochette at (207-212-7356) or Ging Smith at (270-443-0295)