loader image

OLM ASCA Families

Home  /  OLM ASCA Families

June 18 – Picnic at Our Lady of Mercy

Bouncy House Wavier

OLM ASCA June 2026 Picnic Waiver

Family waiver for the ASCA families attending the June picnic at OLM to use the bouncy house.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Family Information

Please complete this registration form for ALL your children. Please fill out the family information below.
Address*

Information – Parents / Guardians

Mother's / Guardian's Name*
Father's / Guardian's Name*

Information – Children

Child 1*
First Name
Last Name
Nick Name
Date of Birth (mm/dd/yy)
Age
Grade entering in fall (NA if too young)
Gender (M/F)
Child 2
First Name
Last Name
Nick Name
Date of Birth (mm/dd/yy)
Age
Grade entering in fall (NA if too young)
Gender (M/F)
Child 3
First Name
Last Name
Nick Name
Date of Birth (mm/dd/yy)
Age
Grade entering in fall (NA if too young)
Gender (M/F)
Child 4
First Name
Last Name
Nick Name
Date of Birth (mm/dd/yy)
Age
Grade entering in fall (NA if too young)
Gender (M/F)
Child 5
First Name
Last Name
Nick Name
Date of Birth (mm/dd/yy)
Age
Grade entering in fall (NA if too young)
Gender (M/F)
Child 6
First Name
Last Name
Nick Name
Date of Birth (mm/dd/yy)
Age
Grade entering in fall (NA if too young)
Gender (M/F)

GENERAL PERMISSIONS

General Permissions Consent*

CODE OF BEHAVIOR

Code of Behavior Consent*

VIDEOS, PHOTOS, and VIRTUAL PLATFORMS

Videos, Photos, and Virtual Platforms Consent*

MEDICAL PERMISSION

Medical Permission Consent*

Medical Information

Our Diocese ask for the information below in case of a medical emergency.
ALLERGIC TO MEDICATIONS:*
Please list the family member and their medication allergies. Do this for all family members who any medication allergies. If no one in the family has any, then please type NA.
ALLERGIC TO FOOD:*
Please list the family member and their food allergies. Do this for all family members who any food allergies. If no one in the family has any, then please type NA.
Please type NA if not applicable.
Please type NA if not applicable.

Medical Insurance Information

EMERGENCY CONTACTS

Contact information for who to call in case of an emergency. Please do not list yourselves. This is who to contact if something happens to you.
Contact 1 – Name*
Contact 2 – Name*

Clear Signature
The parties agree that this document may be electronically signed and that the electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability and admissibility. Transmission via email is not encrypted, so if you are concerned about the security of your sensitive information, please print and fax this form, surface mail it or hand deliver it.

Please click submit when you are finished filling out the form. Thank you!