Totus Tuus Registration 2022

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete a separate registration for each child that will be attending Totus Tuus at St. Patrick Catholic Church in Anamosa.
Grades 7-12 - Totus Tuus will be held June 12 - 16 from 7pm-9pm.
Grades 1-6 - Totus Tuus will be held June 13 - 17 from 9am - 2:30pm.
A morning and evening snack is provided by the church. Lunches should be provided by the parents.

Email *

Student's First and Last Name *

Enter the grade your child will enter in the fall of 2022:

Parent/Guardian First and Last Names

Please choose one of the following

Member at St. Patrick, Anamosa

Member of North Linn Cluster

Other:

Clear selection

Street Address, City, State, Zip Code

Home/cell number of Parent/Guardian 1

Home/cell of Parent/Guardian 2

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Number(s)

Family Physician

Family Physician Phone Number

Family Health Plan Carrier

Policy Number

Allergy Information:

Asthma Information:

Dietary Concerns:

Physical Limitations:

Other medical conditions:

Please check Yes or No after reading: CONSENT AND LIABILITY WAIVER This Consent and Liability waiver is required for and serves both on-site programs and off-site/field trip events/activities for the stated program year. I grant permission for my child to participate in parish/cluster events this year that may require transportation to a location away from the parish/cluster site. The activities will take place under the guidance and direction of parish/cluster employees and/or volunteers. As a parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above-named minor (“Participant”). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend its officers, directors of the parish/cluster and agents, and the Archdiocese of Dubuque, chaperons, or representatives associated with the events, arising from or in connection with my child attending the events or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the parish/cluster, its officers, directors and agents, and the Archdiocese of Dubuque, chaperons, or representatives associated with the events for reasonable attorney’s fees and expenses which they may incur in any action I/we may bring against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/cluster or the Archdiocese of Dubuque. *

Yes

Please check Yes or No after reading: EMERGENCY MEDICAL TREATMENT PERMISSION: 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. 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 contact the emergency contacts/locations as listed in this online registration process.

Yes

Clear selection

Please check Yes or No after reading: ILLNESS NOTIFICATION In the event it comes to the attention of the parish/cluster, its officers, directors and agents and the Archdiocese of Dubuque, chaperons, or representatives associated with any off-site activity or while at parish/cluster that my child becomes ill with symptoms such as vomiting, sore throat, fever, diarrhea, I wish to be notified.

Yes

Clear selection

Please check Yes or No after reading: ALLERGY INFORMATION Does this child have allergic reactions? (medications, foods, plants, insects etc.) If yes, please provide a list of known allergies, reactions, and directives.

Yes

Clear selection

Please Yes or No after reading: ASTHMA INFORMATION Does this child utilize asthma or airway constriction prescription medication? If yes, please provide the parish/cluster with written information on the child’s asthma condition.

Yes

Clear selection

Please Yes or No after reading: PRESCRIBED DIET INFORMATION Does this child have a medically prescribed diet? If yes, please provide the parish/cluster with additional written information on the diet.

Yes

Clear selection

Please Yes or No after reading: LIMITATIONS INFORMATION Does this child have any physical limitations that require accommodations by the parish/cluster? If yes, please provide the parish/cluster with additional written information on the limitations.

Yes

Clear selection

Please Yes or No after reading: OTHER MEDICAL INFORMATION Does this child have any other medical conditions about which the parish/cluster should be aware? If yes, please provide the parish/cluster with additional written information on the medical conditions.

Yes

Clear selection

Please check Yes or No after reading: MEDIA RELEASE AND AUTHORIZATION I understand that by responding “Yes” I hereby grant authority to my child’s parish/cluster for the use of any videos, photos, or similar items to used in social media or on a parish/cluster web page.

Yes

Clear selection

Please check Yes or No after reading: PARTICIPANT INFORMATION RELEASE I understand that by responding “Yes” I hereby grant authority to my child’s parish/cluster for the publication of participant information in the parish/cluster directory and other parish/cluster publications.

Yes

Clear selection

ELECTRONIC SIGNATURE: Please enter your First and Last name below.

Please check one of the following:

Yes = “I am the parent or guardian of the participant named above and have the legal authority to execute the above permission(s). I consent to signing this document electronically as demonstrated by typing my name and checking “Yes” here.”

No = “I am unwilling to sign this form electronically. I understand that I must contact the parish office for a hardcopy of the liability waiver before my child can participate in the program.”

Clear selection

This concludes the Registration for the child you have listed. We look forward to our time together at Totus Tuus!! Thank you!

Please remember that if you want to register more than one child, the registration form must be completed for each attendee. Attendees for Totus Tuus do not have to be a member of our parish. All are welcome to share in the activities and fun of the week with Totus Tuus! Bring your friends!
Fees for the program cost can be paid on the first day of Totus Tuus.
Children in grades 1-6: $45
Students in grades 7-12: $20

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Archdiocese of Dubuque. Report Abuse

Forms