Date Received: _____________ Check # _____________________ SSUUUM M M MM MEEERRR SSTTTRRREEETTTCCCHHH 22001155 SUMMER STRETCH 2015 PARTICIPANT & TENOR R EGISTRATION FORM (Participant = means entering into the 7th, 8th, & 9th grades this Fall) (Tenors = means students entering the 10th grade this Fall) Registration Form acceptance begins immediately and ends on May 15th *Please Print All Information Legibly with special attention to the email address * All below information (front & back) must be completed. A non-refundable $135.00 fee – must be submitted with form. (Confidential financial assistance can be arranged by contacting me). Participant’s name: _______________________________________________________________________________________ (name preferred for a nametag) Grade ENTERING in the Fall of 2015: Grade: _______ School: _________________________________ Age: _____ Gender: _____ Birth Date: ____________ St Ambrose Parishioner: Yes ___ No ___ T-Shirt Size: (adult sizes): SM ____ M ____ LG ____ XL ____ 2XL ___ = an additional $2.00 Please PRINT CLEARLY Student E-Mail: ___________________________________________________________________________________________ (If different from parent) Student Cell # _______________________________________ Uses Texting? Yes __ No __ Parent E-Mail: ____________________________________________________________________________________________ This is extremely helpful for ongoing communication: please PRINT CLEARLY Both Parent First & Last Names:_______________________________________________________________________ Name of Parent most likely to be Driving / Chaperoning: ________________________________________________ Street Address: ___________________________________________________________________________________ City:_____________________________________________ Zip Code:_____________________________ Home # ______________________________________ Work # _____________________________________________ Cell # (MOM) _______________________________________________________ Uses Texting? Yes __ No __ Cell # (DAD)________________________________________________________ Uses Texting? Yes __ No __ Patti Watkins, Director of Faith Formation / [email protected] Saint Ambrose of Woodbury Catholic Church 4125 Woodbury Drive Woodbury, MN 55129 Did you remember to pick a T-SHIRT SIZE?? R EGISTRATION FORM Continued… SSUUUM M M MM MEEERRR SSTTTRRREEETTTCCCHHH 22001155 SUMMER STRETCH 2015 On Wednesdays: June, 24, July, 1, 8, 22, & 29, 2015: 8:00am - 4:30pm Valley Fair is on Wednesday Aug 05,2015 8:00am to 7:00pm 8:00 am Mass at Saint Ambrose Parent Car pools leave Saint Ambrose following Mass to go to service sites Prayer and Lunch at Saint Ambrose – 11:30 a.m. School bus transportation to afternoon activities – 12:30 p.m. 4:30pm pickups at Saint Ambrose I, ________________________________________________, grant permission for ____________________________________________ (Parent / Guardian Name) (Child’s name) to participate in the above named activity and I warrant that my child is in good health. In consideration of my child’s participation, I agree to indemnify Saint Ambrose of Woodbury parish and the Archdiocese of St. Paul and Minneapolis from any claim or law suits brought against Saint Ambrose of Woodbury and the Archdiocese of St. Paul and Minneapolis by myself, child or others, that arises out of any behavior by my child at the event/activity described above. I also agree to pay reasonable attorney’s fees or expenses incurred by Saint Ambrose Woodbury Parish and the Archdiocese in defense of such a claim/lawsuit. EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I give permission to transport my child to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by a doctor or hospital. In the event of an emergency, if you are unable to reach me at the above numbers contact: Emergency Contact: ________________________________________________________________________________ Name (other than parent) Phone number: ____________________________________________________________________________________ Family Health Plan Group Number: _________________________________________________________________________ Family Doctor:_________________________________________________ Phone:__________________________________ Medication my child is presently taking: ______________________________________________________________________ Allergies: ________________________________________________ Does child carry an Epinephrine Pen (Epi-pen): Yes ___ Allergies to drugs: _______________________________________________________________________________________ FOOD Allergies: ________________________________________________________________________________________ Anything you would like us to be aware of with regards to your child?: ______________________________________________ ATTENTION PARENTS; In acceptance and agreement, please INITIAL EACH below: ► I am aware that I am required to attend ONE (1) of the (4) four scheduled Parent meetings. If I fail to attend one (1) of the (4) four Parent meetings I understand and agree that my child will not be able to participate in this year’s Summer Stretch 2015 Program. ________ Parent meeting dates & times to choose from: Tue 05/12: 7PM-9PM; Thurs 05/14: 10AM-12PM; or Thurs 05/21: either 10AM-12PM or 7PM-9PM ► I understand and agree that all Parents of Participants & Tenors (entering the 7th, 8th,9th &10th grades this Fall) are Required to Drive at least two (2) times during the morning portion (8:15am – 12:00pm) of our Summer Stretch Program (Childcare IS provided for our drivers). _______ ► I agree, if I am able, to participate as a parent chaperone for lunch-time duties (11:30am-12:30pm) -and or- for the afternoon (12pm-4:30pm), Recreational Activities on any Wednesday of Summer Stretch 2015 that I will volunteer (this does not, however, take the place of driving requirements). __________ ► I understand that all parent / adult chaperones & drivers must have on file with us: 1) Background check 2) Drivers background check 3) Signed Code of Conduct and 4) Completion of a Virtus training session. And these are all required prior to the start of Summer Stretch Program 2015. ___________ ► All information above is complete along with my $135.00 non-refundable fee (checks can be made out to St. Ambrose of Woodbury Church). ___________ As parent / guardian, I understand and agree to all above considerations and conditions. Parent Signature: _____________________________________________________________ Date:_______________
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