St. Therese Vocation Camp Registration Form

Please also complete the Permission Form below and  mail both in as soon as possible. 


 

Name: ______________________________

 

Address: ____________________________

 

City, State, Zip:_______________________

 

Phone #: ____________________________                                                        T-Shirt Size: _________

 

 

Parish: _____________________________

 

School: _____________________________

 

Grade entering: _______________________

 

Date of birth:  ________________________

Health History

1.                  Does your child have any health or other problems we should know about?  Please explain:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

2.                  Does your child take any medication?  If so, what type, what is it for, when is it taken, who would you like to be responsible for its administration (your son or our staff)?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

3.                  In case of an emergency, please list two or three people and phone numbers for contact:

 

Name: ________________________ Phone #’s:_________________________________ 

Name: ________________________ Phone #’s:_________________________________ 

Name: ________________________ Phone #’s:_________________________________

 

Suggested Donation:

Suggested         Enclosed

4.                  Registration fee:                                                                                    $65.00             _______

 

Please mail to: Vocation Office – 555 Colman Center Drive. - Rockford, IL, 61125.

 

For more information or questions contact the Vocation office:

Phone: 815-399-4300.             E-mail: mail@RockVoc.org.

or visit the Vocation Office web site: www.RockVoc.org 

 

 

 

 

 

INDIVIDUAL PARTICIPANT PERMISSION FORM

 Please also complete the Registration Form above and  mail both in as soon as possible

 

PARENT/GUARDIAN AUTHORIZATIONS  Required of all participants.

 

I hereby give permission for my child/ward _________________________________ to participate in the St. Therese Vocation Camp at Bishop Lane Retreat Center, July 20 - 23, 2008.  I hereby release and indemnify the Diocese of Rockford, its staff and volunteers, all participating parishes and the Catholic Bishop of Rockford from any and all liability arising from claims of any kind or nature whatsoever from my child's participation in this program.  In addition to all activities at Bishop lane Retreat Center, I understand that part of this program is a day trip by bus to Rock Cut State Park,  for hiking, swimming and canoeing.

_____________________________                     ________________________________

     Signature of Parent/Guardian                               Date

 

    _____________________________                     _________________________________

    Address                                                     City/State/Zip

 

*The purpose of this event is vocation awareness.

MEDICAL PERMISSION FORM & INSURANCE INFORMATION

 

I grant permission for the administration of first aid to my child______________________________by the people in charge of the program and those transporting my child to and from the program as their judgement deems advisable, and to make the necessary referrals to qualified physicians for treatment of illness or accidents of a more serious nature.  I understand that I will be promptly notified in the event of any illness or accident and prior to any major surgery, except when delay in such communication would endanger life.  In case of medical emergency, I understand that every effort will be made to contact the parents(guardians) of the participant.  In the event I cannot be reached I hereby give permission to the physician selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery, if deemed necessary for my child.  The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

 

___________________________                        __________________________________

Signature of Parent/Guardian                                 Date

 

___________________________                        ___________________________________

Child’s Physician                                                        Physician's Phone Number

INSURANCE INFORMATION

 

____________________________                      ____________________________________

Insurance Company                                                Policy in the Name of:

____________________________                      ____________________________________

Policy Number                                                        I.D. # or Social Security #

 

On the reverse side of this page, please list any allergies or special medical problems your child may have.

Should it be necessary for our (my) child to return home due to medical reasons or discipline problems, the undersigned will be called and expected to pick up the child or make arrangements for the child to be picked up immediately.

 

_____________________________                     ____________________________________

Signature of Parent/Guardian                                  Date

 

Note: In cases of custody agreement, permission form must be signed by parent(s) who has (have) custody these days.