VBS Child Registration

Contact Information

Registered Family Name REQUIRED Please fill out this field. Please enter valid data.
Father's Name Please enter valid data.
Mother's Name Please enter valid data.
Email REQUIRED Please fill out this field. Please enter an email address.
Home Phone Number Please enter a phone number.
Cell Phone Number Please enter a phone number.
Emergency Contact & Relationship Please enter valid data.
Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Number of Students REQUIRED Please fill out this field.
Student Information 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 Male Female Please fill out this field.
- Grade REQUIRED Please fill out this field. Please enter valid data.
- T-Shirt Size REQUIRED Please fill out this field.
- Special Needs / Allergies Please enter valid data.
- Authorized Pickup Please enter valid data.
Student Information 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 Male Female Please fill out this field.
- Grade REQUIRED Please fill out this field. Please enter valid data.
- T-Shirt Size REQUIRED Please fill out this field.
- Special Needs / Allergies Please enter valid data.
- Authorized Pickup Please enter valid data.
Student Information 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 Male Female Please fill out this field.
- Grade REQUIRED Please fill out this field. Please enter valid data.
- T-Shirt Size REQUIRED Please fill out this field.
- Special Needs / Allergies Please enter valid data.
- Authorized Pickup Please enter valid data.
Student Information 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 Male Female Please fill out this field.
- Grade REQUIRED Please fill out this field. Please enter valid data.
- T-Shirt Size REQUIRED Please fill out this field.
- Special Needs / Allergies Please enter valid data.
- Authorized Pickup Please enter valid data.

Medical Matters
Diocese of Saint Augustine
Catholic Center

To my knowledge, my child is in good health, and I assume all responsibility for the health of my child.

EMERGENCY MEDICAL TREATMENT
In the event of an emergency, I hereby give permission to Diocese of St. Augustine's employees, volunteers, or representatives to seek medical treatment for my child above named.

In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Diocesan representatives or volunteers to hospitalize secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child above named.

I Agree Please select this field.

Media Release
Diocese of Saint Augustine
Catholic Center
11625 Old St. Augustine Road
Jacksonville, Florida 32258

Without compensation, I hereby grant permission to the Catholic Diocese of Saint Augustine to use and reproduce photographs and/or video taken of my child. These photographs may be used for news and editorial purposes in publications and other electronic reproductions (websites and video) 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 photographer, 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 Saint Augustine and all of their employees and agents, from all claims and liability relating to said photographs.

I Agree Please select this field.

Sacramental Fees cover Religious Education materials, sacramental preparation and materials, some retreats, and various other offerings by the RE program.

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 REQUIRED Please fill out this field. Please enter a date.