Religious Ed Registration Form

Family's Last Name: REQUIRED Please fill out this field. Please enter valid data.

Main Contact's Email Address: REQUIRED Please fill out this field. Please enter an email address.

Primary Mailing Address: REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Primary Phone Number REQUIRED Please fill out this field. Please enter valid data.

Number of Students Registering REQUIRED Please fill out this field.
Student 1
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Grade REQUIRED Please fill out this field.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Is this student on any medication? REQUIRED No Yes* (please list below) Please fill out this field.
- *List medication and what it is for if applicable Please enter valid data.
- Medical Allergies?
  Medications, foods, insects, etc. If no allergies please type None
  Please enter valid data.
- Date of last immunization Please enter valid data.
Student 2
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Grade REQUIRED Please fill out this field.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Is this student on any medication? REQUIRED No Yes* (please list below) Please fill out this field.
- *List medication and what it is for if applicable Please enter valid data.
- Medical Allergies?
  Medications, foods, insects, etc. If no allergies please type None
  Please enter valid data.
- Date of last immunization Please enter valid data.
Student 3
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Grade REQUIRED Please fill out this field.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Is this student on any medication? REQUIRED No Yes* (please list below) Please fill out this field.
- *List medication and what it is for if applicable Please enter valid data.
- Medical Allergies?
  Medications, foods, insects, etc. If no allergies please type None
  Please enter valid data.
- Date of last immunization Please enter valid data.
Student 4
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Grade REQUIRED Please fill out this field.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Is this student on any medication? REQUIRED No Yes* (please list below) Please fill out this field.
- *List medication and what it is for if applicable Please enter valid data.
- Medical Allergies?
  Medications, foods, insects, etc. If no allergies please type None
  Please enter valid data.
- Date of last immunization Please enter valid data.

Medical Information

Family Physician REQUIRED Please fill out this field. Please enter valid data.
Physician's Phone Number Maximum 20 characters Please enter a phone number.
Physician's Address Please enter valid data.

Emergency Contact Information

Insurance Information:
Insurance Company Please enter valid data.
Insurance Phone Number Maximum 20 characters Please enter a phone number.
Name of Insured Please enter valid data.
Policy ID Number Please enter valid data.
Group Number Please enter valid data.

No Insurance (Please check if this option applies) I do NOT have insurance at this time

Please select all that apply REQUIRED My child may also be released to the emergency contact adults listed above after the event. My child has a valid driver's license and may drive to and from events. I have received and understand the Minimum Standard Health Protocols Checklist. Please fill out this field.

I request and give my consent for my son/daughter, to participate in all church/school sponsored activities from August 1, 2023 through July 31, 2024, sponsored by Sts. Cyril and Methodius Catholic Church and/or by the Diocese of Victoria. I understand that my son/daughter will be under the supervision of diocesan and/or parish/school personnel. I give my permission to the personnel in charge of the activity to search my child’s belongings, bag, backpack, or other container as deemed necessary. As parent or legal guardian I agree to defend, indemnify and hold harmless the Diocese of Victoria and Sts. Cyril and Methodius Catholic Church, its clergy, officers, agents, employees and volunteers from any claims, costs or expenses for property damages, personal injuries, illness, disease (e.g. COVID-19), and/or other damages arising out of my son/daughter's participation in the above mentioned activity or during the transportation to and from the event. I grant permission for routine nonsurgical medical care to be given to my son/daughter if deemed advisable by the supervising diocesan and/or parish personnel. In case of an emergency, I also grant permission to transport my child to the nearest hospital for emergency medical treatment and for an authorized adult sponsor to sign for treatment if I cannot be located.

Agree to above statement REQUIRED I agree Please fill out this field.

I understand it is my responsibility to read the Minimum Standard Health Protocols Checklist appropriate to my child’s activity from the State of Texas website: https://open.texas.gov/ REQUIRED I agree Please fill out this field.

Video/ Photo/ Media/ Audio Release I hereby give permission for my son/daughter to be photographed or videotaped. I realize that the photo may be published in the newspaper, a magazine or other publications. The video may be used for educational purposes or informational purposes regarding programs or curriculum. A picture may be taken for a craft memento.

Agree to above statement REQUIRED I agree Please fill out this field.

Technology Release I hereby give permission for my minor child to be contacted through social media or other electronic communications. These communications will only be used for ministry purposes such as announcements, scheduling of events, and similar notifications.

Agree to above statement REQUIRED I agree Please fill out this field.

Fees:

How many students are you registering? REQUIRED Please fill out this field.

Sts. Cyril & Methodius
Catholic CHurch

Shiner, Texas

Religious Ed Registration Form

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