St. Clare of Assisi Catholic Church

Houston, TX

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VBS 2023 Child Participant Registration

- Faith Formation

Child Participant Registration
The maximum number of form submissions has been reached. This form is currently not available.
- All children entering Kindergarten through 5th grade in the Fall of 2023 are invited to register for Vacation Bible School. Please register by filling out the form below (one form per child) and submitting the registration fee via cash or check to the St. Clare of Assisi Parish Office.
- Child Participant Information
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Address REQUIRED Please fill out this field. Please enter valid data.
- Address Line 2 Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Status in the Fall 2023 REQUIRED Please fill out this field.
- T-Shirt Size REQUIRED Please fill out this field.
- Parent/Guardian Information
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- First Name Please enter valid data.
  
  Last Name Please enter valid data.
- Email Please enter an email address.
- Phone Number Maximum 20 characters Please enter a phone number.
- Emergency Contact Information
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Emergency Contact Relationship REQUIRED Please fill out this field. Please enter valid data.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Insurance & Medical Information
  
  Personnel will take reasonable care to see that the following information will be held in confidence.
- Name of Doctor REQUIRED Please fill out this field. Please enter valid data.
- Doctor Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Medical Conditions/Special Needs REQUIRED Please fill out this field.
- Allergies/Special Notes REQUIRED Please fill out this field.
- Medications
  Please list all medications your child is currently taking. Your child will bring all such medications, well labeled, that are necessary. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency are as follows:
- Does your child have medical insurance coverage at this time? REQUIRED Please fill out this field.
- Insurance Carrier Please enter valid data.
- Name of Insured Please enter valid data.
- Insurance Policy Number Please enter valid data.
- Consent & Liability Waivers
- Consent and Liability Waiver
  I grant my permission for my child(ren) to participate in Vacation Bible School. In the event of any accident or injury, I agree on behalf of myself, my child(ren)'s other parent if known or living, the child(ren) named above or our heirs, successors and assigns, to hold harmless and defend the Archdiocese of Galveston-Houston, St. Clare of Assisi Catholic Church (its pastor and other agents etc.) or any other representatives associated with the scheduled activity, unless the parties involved were careless.
  I Agree Please select this field.
- Medical Waiver
  I hereby warrant to the best of my knowledge, my child(ren) is/are in good health, and I assume all responsibility for the health of my child. In case of an emergency and I cannot be reached, please contact the emergency contact listed above. In the event of an emergency, I hereby give permission to the staff of St. Clare of Assisi Catholic Church to seek emergency medical transport and/or treatment for my child(ren) named above. I will be responsible for all costs incurred. I wish to be advised before further care is given by the hospital or doctor.
  I Agree Please select this field.
- Video & Photography Consent
  As a parent/guardian, I understand that promotional pictures and videos (individual and group) may be taken during Vacation Bible School. I give permission for my child(ren)'s pictures (named above) to be used for church promotional materials such as newsletters, web pages, social media, calendars, Power Point presentations, or videos to promote or highlight activities of the children participating in Vacation Bible School.
  I Agree Please select this field.
- Electronic Signature REQUIRED Please fill out this field. Please enter valid data.
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VBS 2023 Child Participant Registration

Child Participant Information

Parent/Guardian Information

Emergency Contact Information

Insurance & Medical Information

Consent & Liability Waivers