Kids&#039; Corner (Renew, Relax, Reset Retreat)

Kids' Corner Registration

Parent's Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Street 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.
Phone Number REQUIRED Please fill out this field. Please enter valid data.
I would like this number to be used to text when a parent/guardian is needed during the event.
I Agree Please select this field.
Email Address REQUIRED Please fill out this field. Please enter valid data.
Parent 2 Please enter valid data.
Phone Number Please enter valid data.
I would like this number to be used to text when a parent/guardian is needed during the event. REQUIRED Please fill out this field.
Email Address: Please enter valid data.
Street Address (If different than Adult 1): Please enter valid data.
City Please enter valid data.

State

Zip Please enter a zip code.

Family Medical Information

Emergency Contact (Cannot be a parent/guardian) REQUIRED Please fill out this field. Please enter valid data.
Relationship to Student(s) REQUIRED Please fill out this field. Please enter valid data.
Emergency Contact's Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Family Doctor's Name REQUIRED Please fill out this field. Please enter valid data.
Family Doctor's Phone Number REQUIRED Please fill out this field. Please enter valid data.
Health Plan Carrier REQUIRED Please fill out this field. Please enter valid data.
Health Plan Policy Number Please enter valid data.
If your student(s) has any medical information we should be aware of, please let us know using the text field below with their name by their information. This could include but not limited to: allergies, asthma, dietary needs, physical limitations, etc. REQUIRED Please fill out this field.

Participant Information

First Child
First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Age REQUIRED Please fill out this field. Please enter valid data.
Gender REQUIRED Please fill out this field.
Use this area to let us know any needs this specific child has while they will be at Kids' Corner and any dietary needs we need to be made aware of:
Second Child
First Name Please enter valid data.

Last Name Please enter valid data.
Age REQUIRED Please fill out this field. Please enter valid data.
Gender
Use this area to let us know any needs this specific child has while they will be at Kids' Corner and any dietary needs we need to be made aware of:
Third Child
First Name Please enter valid data.

Last Name Please enter valid data.
Age REQUIRED Please fill out this field. Please enter valid data.
Gender
Use this area to let us know any needs this specific child has while they will be at Kids' Corner and any dietary needs we need to be made aware of:
4th Child
First Name Please enter valid data.

Last Name Please enter valid data.
Age REQUIRED Please fill out this field. Please enter valid data.
Gender
Use this area to let us know any needs this specific child has while they will be at Kids' Corner and any dietary needs we need to be made aware of:

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

I agree REQUIRED Yes Please fill out this field.

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.

I agree REQUIRED Yes No Please fill out this field.

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.

I agree REQUIRED Yes No Please fill out this field.

NONPRESCRIPTION MEDICATION PERMISSION

I hereby grant permission for nonprescription medication (such as ibuprofen, Tylenol, throat lozenges, etc.) to be given to my child in the event a condition arises after my child is already in attendance at a parish/cluster program/activity.

I agree REQUIRED Yes No Please fill out this field.

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.

I agree REQUIRED Yes No Please fill out this field.

Electronic Signature -

Please enter your First and Last Name: two fill-in boxes (First and Last Name)

“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.”

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

I agree REQUIRED Yes No Please fill out this field.

Kids' Corner (Renew, Relax, Reset Retreat)

First Child

Second Child

Third Child

4th Child

Notre Dame Parish

Notre Dame School