St. Patrick Catholic Church
Vacation Bible School 2015
“Cool Kingdom Party”
Mary Leads Me Closer to Jesus
July 6 through 10
9:00 a.m. – Noon
th
th
Pre-K (potty-trained), and Rising Kindergarten – Rising Fifth Grade
$40 per child, $60 for 2 children, $80 for 3 children, $100 per family
Space is limited! Please register early. 
FAMILY NAME: ________________________________________Email:_________________________________
ADDRESS:___________________________________________________________________________________
Number & Street
Daytime Telephone:
City
Zip Code
_________________/_________________cell __________________/_______________cell
Father
Mother
Emergency Contact:_____________________________________________________________________________
Name
Phone
Relationship to child
Child(ren) may be picked up by:  Parents  Brother/Sister Other___________________________________
Camper’s Name
Last, First, Middle
M F
Grade
Entering
Fall 2015
Date of Birth
T-shirt
Size
Allergies?
Special Requirements?
Registration forms may be dropped off at the Religious Education Office, or mailed to:
St. Patrick Religious Education Office, 9151 Elys Ford Road, Fredericksburg, VA 22407
Please make checks payable to St. Patrick Church
The Religious Education Office may be reached at 540-785-7857
e-mail: [email protected]
PLEASE COMPLETE THE PERMISSION SLIP ON THE
REVERSE SIDE OF THIS FORM.
Saint Patrick Catholic Church
9151 Elys Ford RoadFredericksburg, VA 22407
PERMISSION SLIP AND MEDICAL RELEASE
I, ________________________________________(parent/guardian) give permission for my
child(ren) listed on the front of this form, to participate in the St. Patrick Vacation Bible School
from Monday July 6, 2015 to July 10, 2015 from 9:00 a.m.- Noon each day. In the event that I
cannot be reached, I hereby grant permission for my child to be evaluated, diagnosed, treated
and/or medicated in accordance with standard medical practice by licensed medical personnel.
Please provide all necessary information about insurance:
Insurance Carrier: _______________________________ Policy Number: _________________
*I will not hold Saint Patrick or the Diocese of Arlington, chaperones, or representatives in association
with this activity responsible in the event of injury.
My child is allergic to (medication, food, insects, other)
____________________________________________________________________________
My child is taking medication (indicate dosage, frequency, etc.):
____________________________________________________________________________
You should be aware of these special medical conditions of my child (dietary, asthma and other
concerns):
____________________________________________________________________________
Parent's Signature: _______________________________________Date:_________________
I understand that photos of the children will be taken during activities and hereby grant permission for my
child(ren)’s image to be displayed in a photo or media slide show presentation that will not be distributed
to anyone.
Parent's Signature: _______________________________________Date:_________________