2023 VBS Registration

Registered Member at St. Joseph? REQUIRED Yes No Please fill out this field.

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.

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

Will parent/guardian or emergency contact be on site at VBS? REQUIRED Yes No Please fill out this field.

Father's/Guardian #1 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.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Email REQUIRED Please fill out this field. Please enter an email address.

Mother's/Guardian #2 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.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Email REQUIRED Please fill out this field. Please enter an email address.

Emergency Contact Information (during class time)

Contact Name REQUIRED Please fill out this field. Please enter valid data.
Contact Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.

Number of Children Registering 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.
- Gender REQUIRED Please fill out this field.
- Grade Level (as of Spring 2023) REQUIRED Please fill out this field.
- T-Shirt Size REQUIRED Please fill out this field.
- List Any Special Considerations Please enter valid data.
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.
- Gender REQUIRED Please fill out this field.
- Grade Level (as of Spring 2023) REQUIRED Please fill out this field.
- T-Shirt Size REQUIRED Please fill out this field.
- List Any Special Considerations Please enter valid data.
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.
- Gender REQUIRED Please fill out this field.
- Grade Level (as of Spring 2023) REQUIRED Please fill out this field.
- T-Shirt Size REQUIRED Please fill out this field.
- List Any Special Considerations Please enter valid data.
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.
- Gender REQUIRED Please fill out this field.
- Grade Level (as of Spring 2023) REQUIRED Please fill out this field.
- T-Shirt Size REQUIRED Please fill out this field.
- List Any Special Considerations Please enter valid data.
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.
- Gender REQUIRED Please fill out this field.
- Grade Level (as of Spring 2023) REQUIRED Please fill out this field.
- T-Shirt Size REQUIRED Please fill out this field.
- List Any Special Considerations Please enter valid data.
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.
- Gender REQUIRED Please fill out this field.
- Grade Level (as of Spring 2023) REQUIRED Please fill out this field.
- T-Shirt Size REQUIRED Please fill out this field.
- List Any Special Considerations Please enter valid data.
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.
- Gender REQUIRED Please fill out this field.
- Grade Level (as of Spring 2023) REQUIRED Please fill out this field.
- T-Shirt Size REQUIRED Please fill out this field.
- List Any Special Considerations Please enter valid data.
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.
- Gender REQUIRED Please fill out this field.
- Grade Level (as of Spring 2023) REQUIRED Please fill out this field.
- T-Shirt Size REQUIRED Please fill out this field.
- List Any Special Considerations Please enter valid data.
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.
- Gender REQUIRED Please fill out this field.
- Grade Level (as of Spring 2023) REQUIRED Please fill out this field.
- T-Shirt Size REQUIRED Please fill out this field.
- List Any Special Considerations Please enter valid data.
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.
- Gender REQUIRED Please fill out this field.
- Grade Level (as of Spring 2023) REQUIRED Please fill out this field.
- T-Shirt Size REQUIRED Please fill out this field.
- List Any Special Considerations Please enter valid data.

Medical Release

Medication: The Office of Religious Education will not dispense any medication. Students may not have any medication in their possession during PREP classes except metered dose asthma inhalers, epinephrine auto-injectors (epi-pens) or epinephrine inhalers prescribed by their physician. If your child needs to carry an asthma inhaler, epi-pen, or epinephrine inhaler, please contact the Office of Religious Education prior to the beginning of the PREP class year.

Medical Release: By agreeing with this medical release: I hereby warrant, to the best of my knowledge, that my children listed in this St. Joseph’s Catholic Church PREP registration form, are in good health, and I assume all responsibility for the health of these children. In the even of an emergency, I hereby give permission to St. Joseph’s Catholic Church and the Diocese of St. Augustine employees, volunteers, or representatives, to seek medical treatment for these children. In the event any contacts listed on this form cannot be reached in an emergency, I hereby give permission to the physician selected by St. Joseph’s Catholic Church/Diocese of St. Augustine employees, volunteers, or representatives, to hospitalize, secure proper treatment for, and to order any injections, anesthesia and/or surgery for these children. In the event it comes to the attention of St. Joseph’s Catholic Church/Diocese of St. Augustine employees, volunteers, or representatives, that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, or diarrhea, all contacts listed on this form will be called until someone is reached who can pick up this child.
Do you accept? REQUIRED I accept I do not accept Please fill out this field.
Signature:
DISCLAIMER: By typing your name below, you are signing this release electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
First Name REQUIRED Please fill out this field. Please enter valid data.

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

Photo Release Policies & Acceptance

In the past, photos of PREP activities have been shared in our parish newsletter, church bulletin, and on our parish website. We require parental permission for any sharing or publication of photos. Kindly review the photo release policies below and indicate whether you agree to these terms. Thank you!

Child Photo Release

Without compensation, I hereby grant permission to the Catholic Diocese of St. Augustine to use and reproduce photographs and/or video taken of my child. These photographs may be used for news and editorial purposed in publications and other electronic reproductions (websites and video, including livestream) and/or brochures. In addition, I grant my permission to alter the same photos without restriction and to copyright the same. I hereby release the photographers, the journalists, and the publications or media outlets they represent, as well as the parish/church and/or school involved, the Bishop of the Diocese of St. Augustine, a corporation sole, the Catholic Diocese of St. Augustine, and all their employees and agents, from all claims and liability relating to said photographs.
Do you accept? REQUIRED I accept I do not accept Please fill out this field.
Signature:
DISCLAIMER: By typing your name below, you are signing this release electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
First Name REQUIRED Please fill out this field. Please enter valid data.

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

Adult Photo Release

Without compensation, I hereby grant permission to the Catholic Diocese of St. Augustine to use and reproduce photographs and/or video taken of me. These photographs may be used for news and editorial purposed in publications and other electronic reproductions (websites and video, including livestream) and/or brochures. In addition, I grant my permission to alter the same photos without restriction and to copyright the same. I hereby release the photographers, the journalists, and the publications or media outlets they represent, as well as the parish/church and/or school involved, the Bishop of the Diocese of St. Augustine, a corporation sole, the Catholic Diocese of St. Augustine, and all their employees and agents, from all claims and liability relating to said photographs.
Do you accept? REQUIRED I accept I do not accept Please fill out this field.
Signature:
DISCLAIMER: By typing your name below, you are signing this release electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
First Name REQUIRED Please fill out this field. Please enter valid data.

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

Assumption of Risk & Waiver of Liability Relating to COVID

Diocese of St. Augustine

The novel coronavirus (“COVID-19”) has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly through person-to-person contact. As a result, federal, state, and local governments, and federal and state health agencies, recommend social distancing and have, in many locations, prohibited the congregation of groups of people. St. Joseph Catholic Church has put in place preventative measures to reduce the spread of COVID-19; however, we cannot guarantee that you or your child(ren) will not become infected with COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending programs offered by the parish, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the parish may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, coaches, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at any parish sponsored programming (“claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless St. Joseph Catholic Church and the Diocese of St. Augustine, and all of their current, former, and future agents, representatives, religious, and employees and related entities (collectively, “the Diocese”) of and from the claims, including all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of the Diocese, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any parish program.
Do you accept? REQUIRED I accept I do not accept Please fill out this field.
Signature:
DISCLAIMER: By typing your name below, you are signing this release electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
First Name REQUIRED Please fill out this field. Please enter valid data.

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

Payment Information

First Child $50.00
Second Child $40.00 (add'l)
Add'l Child $20.00 (each)
Total $ Please enter an integer (number).
Payment Type REQUIRED PayPal® Check Cash Please fill out this field.
Name associated with your PayPal® account OR Name on your check & check #: Please enter valid data.

Comments

Confirmation Email Please enter an email address.

2023 VBS Registration

2023 VBS

Registration Form

VBS Online Payment