SCUBA Registration Form
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Vacation Bible School Registration B.C.C.N
1) NAME:
Age:
Gender:
Allergies/medical conditions/special needs:
 *
2) NAME:
Age:
Gender:
Allergies/medical conditions/special needs :
3) NAME:
Age:
Gender:
Allergies/medical conditions/special needs :
4) NAME:
Age:
Gender:
Allergies/medical conditions/special needs :
5) NAME:
Age:
Gender:
Allergies/medical conditions/special needs :
NAME OF PARENTS:
 *
STREET ADDRESS:
 *
CITY, STATE, ZIP:
 *
HOME PHONE:
CELL PHONE:
 *
EMAIL ADDRESS:
 *
HOME PARISH:
 *
IN CASE OF EMERGENCY CONTACT:
PHONE NUMBER AND RELATIONSHIP TO CHILD:
 *
OFFICE OF Communication Services
THE ROMAN CATHOLIC Diocese of Helena
Dan Bartleson-Director
Cell: 406-475-0308; Desk: 406-389-7057
dbartleson@diocesehelena.org; https//:diocesehelena.org
Media Release Agreement for Minors
In conjunction with your child/children's participation in an event sponsored by or associated with the Diocese of Helena, you child/children's image, speech, and individual and/or groups projects may be published. Publication may include but not be limited to print and/or digital still pictures, video recording, audio recording or digital or print versions of projects or contributions.

If used, such publication would be associated with the purposes of the Catholic faith and:
*The Roman Catholic Diocese of Helena
*The Bishop of Helena and his offices, ministries or initiatives
*A diocesan Parish, School, Retreat, and/or event

Your Signature below is not required for your child/children to participate in events/activities/projects of the Diocese of Helena. Declining to sign may impact or restrict the nature of participation depending on event plans regarding photos, recording, and publication. Please contact the person responsible for planning  the event for event details.
I understand that media representations of my child/children (e.g. still photos, videos, audio recording) and/or projects created by my child/children may be published by the Bishop of the Roman Catholic Diocese of Helena related to the offices, ministries, parishes, schools, programs, and initiatives of the Diocese.

Event/program my child/children will attend and event dates.
 *
1. Child's Name (print)
 *
2. Child's Name print)
3. Child's Name (print)
4. Child's Name (print):
5. Child's Name (print):
Parents/Guardian Name:
Date:
 *
Parent/Guardian Signature:
 *
P.O. Box 1729 Helena, MT 59624-1729
Phone 406-442-5820 
Fax 406-442-5191
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