Club 3:16 - December 14th
Please complete the form below to register you child(ren) for this exciting Club 3:16 event at St. Joseph Catholic Church.
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Family's Last Name: *
Parent's First Names: *
Phone Number: *
Email Address: *
Person(s) other than parent authorized to pick up child(ren): *
How did you hear about this event? *
CHILD ONE
Please complete the next 4 questions in regards to the same child.
First Name *
Grade *
Date of Birth *
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DD
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YYYY
Allergies or Medications *
CHILD TWO
Please complete the next 4 questions in regards to the same child.
First Name
Grade
Clear selection
Date of Birth
MM
/
DD
/
YYYY
Allergies or Medications
CHILD THREE
Please complete the next 4 questions in regards to the same child.
First Name
Grade
Clear selection
Date of Birth
MM
/
DD
/
YYYY
Allergies or Medications
CHILD FOUR
Please complete the next 4 questions in regards to the same child.
First Name
Grade
Clear selection
Date of Birth
MM
/
DD
/
YYYY
Allergies or Medications
CHILD FIVE
Please complete the next 4 questions in regards to the same child.
First Name
Grade
Clear selection
Date of Birth
MM
/
DD
/
YYYY
Allergies or Medications
GENERAL PERMISSION- All Religious Education Participants
DIOCESE OF PEORIA LIABILITY WAIVER
As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named student. I understand the risks this activity may present to my child, including, but not limited to, a serious personal injury or death. In consideration of my child being allowed to participate in this activity, I hereby release and agree to indemnify and hold harmless, the Diocese of Peoria, the parish, teachers, chaperones, volunteers, or representatives associated with the event, and their employees and agents, from any liability for injuries, damages, medical expenses, or any other loss to my child, family, or me (including attorney’s fees) arising from or related to my child’s participation in this activity.

MEDICAL PERMISSION
I grant permission for the administration of First Aid to my child(ren) listed above by the people in charge of Religious Education at St. Joseph, Pekin, to sign the necessary releases as may be required, and to make the necessary referrals to qualified physicians for the treatment of illness or accidents of a more serious nature. I understand I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life. In the case of a medical emergency, I understand that every effort will be made to contact the parent/guardian of the participant. In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery if deemed necessary for my child.

VIDEOTAPING AND STILL PHOTOGRAPHY
Video, still photographs and audio recordings may be taken during Religious Education. This authorization form constitutes permission for my child(ren)’s participation in videotaping, still photographs, and/or audio recordings, which may be used for future promotional efforts, including the Catholic Diocese of Peoria publications and websites.

GENERAL PERMISSION- All Religious Education Participants *
Required
"For God so loved the world..." - John 3:16
We look forward to seeing your child(ren) at this exciting Club 3:16 event!
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