Bosco Bash 2019 Youth Registration Form

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Diocese of Columbus

This online form must be completed by a parent or guardian and not another person on their behalf.

All registrations made after Noon on February 22 will be considered late and will not be guaranteed a t-shirt at the event.

Name of Parent/Guardian Completing this Form: *

Parent/Guardian Email: *

Name of Parish/School: *

First Name of Youth Participant: *

Last Name of Youth Participant: *

Participant Gender: *

Date of Birth: *

YYYY

Grade: *

T-shirt Size *

Registrations made after 10 AM, Monday, February 25 are not guaranteed a t-shirt. Additional t-shirts will be available on a first-come-first-serve basis for $5 each at the Bosco Bash

Participant Mailing Address: *

City: *

State: *

Zip code: *

Participant Mobile Phone #:

Mother/Guardian First Name: *

Mother/Guardian Last Name: *

Mother/Guardian Phone: *

Father/Guardian First Name: *

Father/Guardian Last Name: *

Father/Guardian Phone: *

Additional Emergency Contact Name: *

Additional Emergency Contact Phone Number: *

Chronic Conditions, special medical conditions, and/or physical limitations: *

(e.g. Epilepsy; Diabetes; Paraplegic; etc.)

Allergic Reactions: *

(e.g. Food; Medications; Plants; etc.)

Dietary Restrictions: *

Current Medication: *

The Participant is taking medication at present. The Participant will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows:

Medical Insurance:

Policy Number:

Insurance Member's Name:

Insurance Phone #:

Family Doctor Name:

Family Doctor Phone #:

Non-Prescription Medication *

Non-prescription medication may be given to the Participant, if deemed appropriate

No medication of any type, whether prescription or non-prescription, may be administered to the participant unless the situation is life-threatening and emergency treatment is required.

Consent to Release of Photographs *

Do you hereby consent to the release of photographs and name of the Participant to be used by the Diocese of Columbus, and its parishes and schools, for future promotional programs of the Diocese, and its parishes and schools?

I consent to the release.

I DO NOT consent to the release.

Permission, Release and Indemnification, and Code of Behavior *

I have read and agree to all the terms and conditions list in the Permission, Release and Indemnification, and Code of Behavior found here: https://columbuscatholic.org/documents/2019/1/Bosco%20Bash%20Permission%20Release%20and%20Idemnification%20and%20Code%20of%20Behavior.pdf

I have read and agree to all the terms and conditions

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