VBS Registration

Please fill out parent first and last name and parent information in this first section.

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

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

Email REQUIRED Please fill out this field. Please enter an email address.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Alternate Phone Number

Please list either a work number, spouse's number, etc in the event we are not able to reach you at the above listed number.

Please enter valid data.

Insurance Name and Group/Member Number REQUIRED Please fill out this field.

Please complete the information below for each child being registered for VBS!

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

Gender? REQUIRED Male Female Please fill out this field.

Birthday (MM/DD/YY) REQUIRED Please fill out this field. Please enter valid data.

Allergies or Medical Conditions? REQUIRED Please fill out this field. Please enter valid data.

Tee Shirt Size REQUIRED Please fill out this field.

If you are registering for more than one child in the same family/parent group-- please continue below. If you are only registering one child, please scroll to the next section and continue with required fields.

Child's Name Please enter valid data.

Gender? Male Female

Birthday (MM/DD/YY) Please enter valid data.

Tee Shirt Size

Allergies or Medical Conditions? Please enter valid data.

Child's Name Please enter valid data.

Gender? Male Female

Birthday (MM/DD/YY) Please enter valid data.

Tee Shirt Size

Allergies or Medical Conditions? Please enter valid data.

Child's Name Please enter valid data.

Gender? Male Female

Birthday (MM/DD/YY) Please enter valid data.

Tee Shirt Size

Allergies or Medical Conditions? Please enter valid data.

Below is Emergency Contact Information and the Liability and Medical Release. Please list the information below carefully as it requires. The Liability and Medical Release is both a waver for participation, a medical release for emergent care, and a media release. Please contact Annie Aker or Jess Bailey if you have any questions or concerns.

Emergency Contact Name (Other Than Parent) REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact Phone Number (With Area Code) REQUIRED Please fill out this field. Please enter valid data.

I give permission for my child to take part in the Sacred Heart of Jesus, Cicero sponsored activities and programs for Vacation Bible School, June 24-28, 2024. In consideration of the opportunity for my child to participate and fully recognizing that such an undertaking involves an element of risk, we assume all risks and hazards incidental in such participation and do hereby release, absolve, indemnify, and agree to hold harmless the Diocese of Lafayette-in-Indiana/Sacred Heart of Jesus Parish its agents, employees and officers, the chaperones, leaders, organizers, sponsors, and persons transporting our child to and/or from these activities. Neither the Diocese of Lafayette-in-Indiana/Sacred Heart of Jesus Parish nor any of said persons shall be held financially responsible for any injury, illness, or death incurred as a direct or indirect result of the activity. I, the undersigned, have read this release and understand all its terms and execute it voluntarily and with full knowledge of the significance. In the event of an emergency and I cannot be contacted, I hereby authorize emergency treatment to be administered.

In the event of an emergency, I hereby give permission to the Sacred Heart of Jesus Catholic Church, it’s staff or adult volunteers, and the Diocese of Lafayette-in-Indiana, agents, representatives, volunteers and employees or either any diocese or any parish/mission thereof, and chaperones or representatives associated with this event to transport my student to a hospital for emergency medical or surgical treatment. I further authorize any medical, dental and/or necessary and proper medical treatment for the care of my student. I understand that I will be notified as soon as possible in the event that an emergency requiring medical assistance should arise.

By clicking "I Agree" below, I acknowledge that the submission of this form is considered agreement to the above statements. REQUIRED I Agree Please fill out this field.

Please Type Full Name of Registering Parent Signing REQUIRED Please fill out this field. Please enter valid data.

Please Type Today's Date to Acknowledge Signing REQUIRED Please fill out this field. Please enter valid data.

I give my permission for my child to be used in forms of media (pictures, videos, livestream, etc). REQUIRED Yes No Please fill out this field.

Please list any prescribed medications below with child's name, medication, dosage, and time to be taken while with us at VBS. As a note-- we will not be administering any "over the counter" medications without doctor's note and must be provided for the child. We will not keep any medications on hand for dosing.

RX Medications REQUIRED Please fill out this field.