Consent Form (REQUIRED)

REGISTRATION CONSENT AND WAIVER FORM FOR YOUTH ACTIVITIES This Form must be completed and executed for participation in the Youth Activities as a part of registration.

Number of Program Participants (Children) REQUIRED Please fill out this field.
Child 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.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Sex REQUIRED Girl Boy Please fill out this field.
- Participant's 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.
- Participant Resides With: REQUIRED Mother Father Guardian(s) Please fill out this field.
- Is Participant taking any medications OR have any medical conditions? (e.g., diabetes, epilepsy, heart conditions, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies? (e.g., insects, hay fever, strawberries, peanuts, etc.) REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies or adverse reactions to medications? (e.g., penicillin, ibuprofen, acetaminophen, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any disabilities or physical or developmental limitations? REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Date of Last Tetanus Immunization Please enter a date.
Child 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.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Sex REQUIRED Girl Boy Please fill out this field.
- Participant's 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.
- Participant Resides With: REQUIRED Mother Father Guardian(s) Please fill out this field.
- Is Participant taking any medications OR have any medical conditions? (e.g., diabetes, epilepsy, heart conditions, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies? (e.g., insects, hay fever, strawberries, peanuts, etc.) REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies or adverse reactions to medications? (e.g., penicillin, ibuprofen, acetaminophen, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any disabilities or physical or developmental limitations? REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Date of Last Tetanus Immunization Please enter a date.
Child 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.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Sex REQUIRED Girl Boy Please fill out this field.
- Participant's 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.
- Participant Resides With: REQUIRED Mother Father Guardian(s) Please fill out this field.
- Is Participant taking any medications OR have any medical conditions? (e.g., diabetes, epilepsy, heart conditions, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies? (e.g., insects, hay fever, strawberries, peanuts, etc.) REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies or adverse reactions to medications? (e.g., penicillin, ibuprofen, acetaminophen, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any disabilities or physical or developmental limitations? REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Date of Last Tetanus Immunization Please enter a date.
Child 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.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Sex REQUIRED Girl Boy Please fill out this field.
- Participant's 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.
- Participant Resides With: REQUIRED Mother Father Guardian(s) Please fill out this field.
- Is Participant taking any medications OR have any medical conditions? (e.g., diabetes, epilepsy, heart conditions, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies? (e.g., insects, hay fever, strawberries, peanuts, etc.) REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies or adverse reactions to medications? (e.g., penicillin, ibuprofen, acetaminophen, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any disabilities or physical or developmental limitations? REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Date of Last Tetanus Immunization Please enter a date.
Child 5
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Sex REQUIRED Girl Boy Please fill out this field.
- Participant's 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.
- Participant Resides With: REQUIRED Mother Father Guardian(s) Please fill out this field.
- Is Participant taking any medications OR have any medical conditions? (e.g., diabetes, epilepsy, heart conditions, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies? (e.g., insects, hay fever, strawberries, peanuts, etc.) REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies or adverse reactions to medications? (e.g., penicillin, ibuprofen, acetaminophen, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any disabilities or physical or developmental limitations? REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Date of Last Tetanus Immunization Please enter a date.
Child 6
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Sex REQUIRED Girl Boy Please fill out this field.
- Participant's 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.
- Participant Resides With: REQUIRED Mother Father Guardian(s) Please fill out this field.
- Is Participant taking any medications OR have any medical conditions? (e.g., diabetes, epilepsy, heart conditions, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies? (e.g., insects, hay fever, strawberries, peanuts, etc.) REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies or adverse reactions to medications? (e.g., penicillin, ibuprofen, acetaminophen, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any disabilities or physical or developmental limitations? REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Date of Last Tetanus Immunization Please enter a date.
Child 7
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Sex REQUIRED Girl Boy Please fill out this field.
- Participant's 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.
- Participant Resides With: REQUIRED Mother Father Guardian(s) Please fill out this field.
- Is Participant taking any medications OR have any medical conditions? (e.g., diabetes, epilepsy, heart conditions, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies? (e.g., insects, hay fever, strawberries, peanuts, etc.) REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies or adverse reactions to medications? (e.g., penicillin, ibuprofen, acetaminophen, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any disabilities or physical or developmental limitations? REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Date of Last Tetanus Immunization Please enter a date.
Child 8
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Sex REQUIRED Girl Boy Please fill out this field.
- Participant's 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.
- Participant Resides With: REQUIRED Mother Father Guardian(s) Please fill out this field.
- Is Participant taking any medications OR have any medical conditions? (e.g., diabetes, epilepsy, heart conditions, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies? (e.g., insects, hay fever, strawberries, peanuts, etc.) REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies or adverse reactions to medications? (e.g., penicillin, ibuprofen, acetaminophen, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any disabilities or physical or developmental limitations? REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Date of Last Tetanus Immunization Please enter a date.
Child 9
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Sex REQUIRED Girl Boy Please fill out this field.
- Participant's 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.
- Participant Resides With: REQUIRED Mother Father Guardian(s) Please fill out this field.
- Is Participant taking any medications OR have any medical conditions? (e.g., diabetes, epilepsy, heart conditions, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies? (e.g., insects, hay fever, strawberries, peanuts, etc.) REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies or adverse reactions to medications? (e.g., penicillin, ibuprofen, acetaminophen, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any disabilities or physical or developmental limitations? REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Date of Last Tetanus Immunization Please enter a date.
Child 10
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Sex REQUIRED Girl Boy Please fill out this field.
- Participant's 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.
- Participant Resides With: REQUIRED Mother Father Guardian(s) Please fill out this field.
- Is Participant taking any medications OR have any medical conditions? (e.g., diabetes, epilepsy, heart conditions, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies? (e.g., insects, hay fever, strawberries, peanuts, etc.) REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any allergies or adverse reactions to medications? (e.g., penicillin, ibuprofen, acetaminophen, etc.) YES NO
- If answered "YES," please explain: Please enter valid data.
- Does Participant have any disabilities or physical or developmental limitations? REQUIRED YES NO Please fill out this field.
- If answered "YES," please explain: Please enter valid data.
- Date of Last Tetanus Immunization Please enter a date.

Custodial Parent/Legal Guardian 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.
Email REQUIRED Please fill out this field. Please enter an email address.
Primary Phone Number REQUIRED Please fill out this field. Please enter a phone number.
Type of Phone REQUIRED Please fill out this field.
Secondary Phone Number Please enter a phone number.
Type of Phone

Primary Doctor

First Name Please enter valid data.

Last Name Please enter valid data.
Phone Number Please enter a phone number.

Health Plan Carrier

Insurance Name Please enter valid data.
Policy # Please enter valid data.
Group # Please enter valid data.
Name of Primary Insured Please enter valid data.

PARTICIPATION PERMISSION: I, the undersigned, am custodial parent/legal guardian of Participant and request that he/she be to allowed participate in the Youth programs, events and activities to be held at St. Thomas More Parish and St. Joseph Catholic Church during the 2019/2020 school/parish year (the “Youth Activities”). I understand that the Youth Activities consist of weekly sessions and related activities which may be held from time to-time.

I Agree Please select this field.

LOST OR STOLEN ITEMS: I hereby understand and agree that neither the Diocese of Tulsa/Archdiocese of Oklahoma City, St. Thomas More University Parish, St. Joseph Catholic Church, nor any of their respective employees, directors, officers, agents, representatives and/or volunteers shall be held liable for any of my or my child’s personal property lost or stolen during participation in the Youth Activities.

I Agree Please select this field.

As a rule, medication will not be administered by Youth Program staff. The exception is a youth program or activity that includes an extended day or overnight activity. If medication is required a separate Consent and Waiver Medication Form must be completed prior to the activity.

CONSENT TO TREATMENT OF PARTICIPANT: I am the custodial parent or legal guardian of Participant. I hereby warrant that, to the best of my knowledge, Participant is in good health and physically able to participate in the Youth Activities, and I assume all responsibility for the health, physical condition, and ability of Participant to so participate. In the event of circumstances that indicate that Participant is in need of immediate medical care, I authorize and give permission for Participant to be transported to a hospital/clinic/medical facility for evaluation and emergency medical or surgical treatment, including any necessary X-ray examination. I authorize any licensed physician or medical center to treat Participant. I accept full responsibility for any medical or hospital bills associated with the care of Participant.

I Agree Please select this field.

LIABILITY WAIVER: In consideration of the arrangement set forth herein, I do on behalf of myself, Participant and our respective heirs, successors, assigns and next of kin, release, waive, hold harmless, defend and covenant NOT TO SUE, St. Thomas More University Parish, St. Joseph Catholic Church, the Bishop of the Diocese of Tulsa/Archdiocese of Oklahoma City, and/or the Diocese of Tulsa/Archdiocese of Oklahoma City, and each of their respective departments, directors, administrators, teachers, officers, agents, representatives, volunteers and employees from any and all actions, claims, demands or liabilities, including without limitation, those for personal injuries or property damage, that I and/or Participant may suffer due to illness or injury suffered by Participant as a result of, or in connection with, participation in the Youth Activities, including the administration of authorized medications, medical treatment and any consequences that may arise as the result of said treatment, including without limitation, housing, meals and collateral entertainment to the fullest extent permitted by law. I certify to you that the information contained herein is true and correct to the best of my knowledge and that I fully understand the terms and legal consequences of my execution of this REGISTRATION CONSENT AND WAIVER FORM FOR YOUTH ACTIVITIES.

I Agree Please select this field.

By typing your full, legal name in the box below, you are indicating that you are the custodial parent/legal guardian of the participant(s), that all of the above information is complete and accurate, that you understand and accept all above statements, and that you are allowing St. Thomas More University Parish, St. Joseph Parish, Totus Tuus, the Archdiocese of Oklahoma City, and the Diocese of Tulsa to accept your typed name as your digital signature which will be considered equivalent to your handwritten signature.

Please, type your full legal name to indicate your digital signature and completion of this document. REQUIRED Please fill out this field. Please enter valid data.

ALL PARTICIPANTS FOURTEEN YEARS OF AGE AND OLDER must read and agree to the following statement: I acknowledge that I agree to conduct myself in a manner consistent with the policies of the St. Thomas More Parish and that failure to do so may result in my being required to leave the Youth Activity, and not being allowed to participate in future programs and activities, at the discretion of the Parish/School.

Please, type your full legal name to indicate your digital signature and agreement with the above statement. Please enter valid data.

ST. THOMAS MORE

UNIVERSITY PARISH
and STUDENT CENTER

Consent Form (REQUIRED)