Totus Tuus Registration

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St. Theresa of the Child Jesus Catholic Church

Email *

Parents Names *

Address *

Home phone *

Mom Cell # *

Dad Cell # *

Name of Child(ren), any Allergies, Grade 2019-2020 *

Additional Emergency Contact Name & Phone # *

Family Physician Name & Phone # *

Insurance Company & Policy # *

Medical Authorization:I understand that the Catholic Arch/Diocese of Birmingham and Totus Tuus assume no responsibility for accidentswhich may occur in association with diocesan events and activities. I agree to use my/our personal insurance to cover any suchincidents. I understand that, in the event medical intervention is needed, every attempt will be make to contact the persons listedabove. In the event those individuals cannot be reached, I/We hereby give permission to the physician or any other qualified medicalstaff selected by the event leader to hospitalize, secure medical treatment, and/or order injection, anesthesia, or surgery for Participantas deemed necessary. *

Yes

Permission for Other Medical Matters: In the event it comes to the attention of the Diocesan and/or parish chaperones that my child complains of illness, I grant permission for non-prescription medication (such as Tylenol, lozenges, etc.) to be given to Participant. *

Yes

Code of Behavior for Youth and Adults:I agree to abide by and/or instruct my child to abide by all rules and regulations as outlined by the aforementioned chaperones/representatives. I agree that if I/Participant fail(s) to abide in any way by the rules, that I/Participant can be dismissed from the eventand sent home immediately at my/Participant’s expense with no right of reimbursement or refund for any amount in connectiontherewith from the Catholic Arch/Diocese of Birmingham or its chaperones/representatives. *

Yes

Release of Liability for Youth and Adults:I understand all reasonable safety precautions will be taken at all times by the Catholic Arch/Diocese of Birmingham and Totus Tuus and its employees and agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree to indemnify and hold harmless the Catholic Arch/Diocese of Birmingham and Totus Tuus, its leaders, employees and volunteer staff from any and all claims arising from or inconnection with attending this event. *

Yes

Photo release: I hereby authorize the Catholic Arch/Diocese of Birmingham and Totus Tuus and its agents to utilizephotographic and/or video images of me or my child by the Catholic Arch/Diocese of Birmingham. In giving myconsent, I hereby indemnify and hold harmless the Catholic Arch/Diocese of Birmingham and Totus Tuus and its agents from any and all responsibility of liability. I understand that I will receive no compensation should any photograph and/or video of me or my child be used. *

Yes

Electronic Signature of Parent

A copy of your responses will be emailed to the address you provided.

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