Medical History, Liability & Special Permissions
Thank you for completing your online registration form. In order to complete the process, we'd also like you to fill out some additional information. Please contact Steph Hansen if you have any questions. Thank you & God Bless!
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Email *
Family Name - Last Name *
Current Address (or addresses if parents are separated) *
Authorization for Safe Environment Lesson *

I understand that the Green Bay Diocese requires all parishes to teach children each year about having a safe environment which helps to prevent child sex abuse.  This includes information about our dignity in being created in God's image; what is appropriate and inappropriate touch; and what to do in an uncomfortable or abusive situation.  Starting in grade 4 the dangers of pornography are also discussed as the average age for first exposure is 8-11 years old.  I give permission for my child/children to be part of this 20 min. lesson. (If you prefer not to check yes to this, information can be sent home for you to teach your child yourself.)

Permission to contact children in grades 6-12 through Social Media/Electronic Communications *

I give permission for ministry representatives (i.e. Steph) to digitally communicate with my child/children (in grades 6-12)  regarding youth activities that they are involved in. 

Authorization for Transportation to Off-Site Events my child registers for *
I grant permission for my child/children to participate in events organized by S.S. Peter and Paul Parish,  for this current fiscal year. I understand I will be asked about each event in particular before my son/daughter participates and that this form simply means less forms for each individual event.   If the event is offsite, I also grant permission for my child to be transported by means of official transportation organized by SS. Peter and Paul or the Diocese of Green Bay or their representatives.

 As parent and/or legal guardian, I remain legally responsible for any personal actions taken by my child/children. I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend S.S. Peter and Paul its officers, directors, employees and S.S. Peter and Paul agents, and the Diocese of Green Bay, its employees and agents, chaperones, or representatives associated with the event, from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish/school, its officers, directors and agents, and Diocese of Green Bay its employees and agents and chaperones, or representative associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/school or the Diocese of Green Bay.

Your name below signifies your signature. 

Printed Media Permission *

I hereby give my permission for my child/children's picture or image and full name to be used in church publications, bulletins, newsletters, and newspapers.  

Digital Media Permission *

I hereby give my permission for my child/children's picture or image and full name to be used in church publications online, including facebook, website, etc. 

Authorization to Medically Transport *

I authorize SS. Peter & Paul personnel to transport my son/daughter to a physician’s office and/or emergency room for treatment in the event of a medical emergency and care is required.  I authorize the Physician and Hospital Staff to treat my son/daughter, as they deem necessary in the emergency.  An ambulance will be called depending on the severity of the circumstance. Your name below signifies your signature. 

Insurance Information: Health Insurance Company, Address & Phone Number
If none, you can leave blank
Insurance Information: Member ID Number or Group Number
If none, you can leave blank
Family Physician & Phone No:
Preferred Hospital & Phone No:
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