Saint John the Apostle Catholic Church                     Parent/Guardian Consent Form & Liability Waiver
Parish:
St. John the Apostle Catholic Church: 1968 Sandbridge Rd., Virginia Beach, VA 23456

Type of Events:
This form covers your teen for Confirmation liability form requirements, as well as ALL youth group events they might attend for the 2021-2022 academic school year and summer.

Destination of Events:
Saint John the Apostle Catholic Church and/or other venues determined by advertised flyers and by specific registration by participants. (i.e. summer field trips, outdoor events, or diocese events in other locations.)

Individual(s) in Charge:
SJA Youth Minister, Members of the C.I.A. Youth group Core Team, Parent Chaperones, ALL VIRTUS trained adult volunteers trained by Saint John the Apostle Catholic Church.
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Email *
FAMILY INFORMATION:
Mother and Father's Full Names *
Street Address, City, State & Zip Code: *
Home Phone Number: *
Father's & Mother's Email address: *
Father's & Mother's Cell Phone Number: *
EMERGENCY CONTACT INFORMATION
Full Name of Emergency Contact Person: *
Contact Number: *
Relationship to Child: *
INSURANCE INFORMATION:
Insurance Company *
Policy Holder's Name: *
Policy Number: *
Family Physician Name: *
Family Physician Phone: *
CHILD INFORMATION
Child #1
Child #1's Full Name, School & Grade: *
Child #1's Cell Phone Number, Email & T-shirt Size: *
CHILD #2:
Child #2's Full Name, School & Grade
Child #2's Cell Phone Number, Email & T-shirt size
CHILD #3:
Child #3's Full Name, School,  & Grade:
Child #3's Cell Phone Number, Email, & T-shirt Size:
CHILD MEDICAL INFORMATION
Child #1's First Name (Include Last if different): *
Child #1's Date of Birth (MM/DD/YYYY) *
Child #1's Gender: *
Does Child #1 have any allergies? *
If Yes, what allergies does Child #1 have?
Does Child #1 take any medication? *
If Yes, what medication does Child #1 take?
Does Child #1 have an other Physical or Emotional Conditions? *
Child #2's First Name (Include Last if different):
Child #2's Date of Birth (MM/DD/YYYY):
Child #2's Gender:
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Does Child #2 have any allergies?
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If Yes, what allergies does Child #2 have?
Does Child #2 take any medication?
Clear selection
If Yes, what medications does Child #2 take?
Does Child#2 have any other Physical or Emotional Conditions?
Child #3's First Name (Include last if different):
Child #3's Date of Birth (MM/DD/YYYY):
Child #3's Gender:
Clear selection
Does Child #3 have any allergies?
Clear selection
If Yes, What allergies does Child #3 have?
Does Child #3 take any medication?
Clear selection
If Yes, What medication does Child #3 take?
Does Child#3 have any other Physical or Emotional Conditions?
PLEASE READ THIS STATEMENT BELOW AND TYPE YOUR FULL NAME IN THE SPACE PROVIDED AS YOUR ELECTRONIC SIGNATURE:
I, [Parent/Guardian named above] grant permission for my child(ren) [named above] to participate in any Saint John the Apostle Catholic Church sponsored event(s) for which they are registered throughout the year. I understand that these events will take place under the guidance and direction of parish employees and/or volunteers from the parish [named above].

In the event of an emergency, I give authority to the accompanying adults to authorize treatment. I understand that an attempt to notify me will be made before any treatment is authorized.

As parent/legal guardian, I remain legally responsible for any personal action taken by my child. I agree to hold harmless Saint John the Apostle Catholic Church and the Diocese of Richmond as well as it officers, directors, agents, chaperones, or representatives associated with this event, arising from or in connection with my child attending this event, or including but not limited to accidents, emergencies, exposure to reckless conduct of persons.  
TYPE YOUR FULL NAME IN THE SPACE PROVIDED BELOW UNDERSTANDING THAT THIS ACTS AS YOUR ELECTRONIC SIGNATURE: *
DATE: *
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