VBS 2022 Camper Registration

Information - Parent / Guardian

Name*

First Last

Cell*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Registered OLM Parishioner?*

Yes. I am a parishioner.
No. I am not a parishioner.

Information - Parent / Guardian 2

Name

First Last

Cell

Registration for VBS Campers, Kindergarten (Age 4) through Grade 5

Camper Information:*

First Name	Last Name	Date of Birth	Age	Grade Ent.	Gender (M/F)

Hit the plus sign to add additional children.

Placement of Siblings

If applicable, please select yes or no.

Placement of Siblings

Yes, please place my children in the same group.
Please do NOT place my children in the same group.

Comments or Questions

Confidential Information- Please type NA if not applicable.*

To best support you and your child(ren), please let us know of any physical limitations, learning challenges, special needs and/or family circumstances (recent separation, divorce, death or illness). Please contact Mary Jo (331-707-5378) prior to the start of VBS so we may learn how to support you in the care of your child(ren)’s needs and growing faith. Thank you!

GENERAL PERMISSIONS

General Permissions Consent*

Yes, I consent.

I agree on behalf of myself, my heirs, assigns, executors, and personal representatives, to hold harmless and defend Parish, Our Lady of Mercy Catholic Church, and the Diocese of Joliet, ifs officers, directors, agents, employees, or representatives from any and all liability for illness or death arising from or in connection with my participation.

VIDEOS, PHOTOS, AND VIRTUAL PLATFORMS CONSENT

Videos and/or photos may be taken during this event. This authorization consent constitutes permission to use my child(ren)'s image in video and/or photos which may be used for future promotional efforts including the parish and /or Diocese of Joliet website.

Consent*

Yes, I consent to the use of images of my child(ren).
No. Do not use images of my child(ren).

CODE OF BEHAVIOR

INFRACTION OF THESE RULES CAN MEAN IMMEDIATE DISMISSAL WITH NO REFUND.

Code of Behavior Consent*

Yes, I consent to the Code of Behavior.

I acknowledge that I am representing our diocese/parish during this event, and I will represent us well. I will adhere to all Diocesan
Guidelines and display responsible, mature, and respectful behavior in my words, actions, and usages.

Expectations
1. All participants are expected to arrive on time.
2. All participants are expected to demonstrate respect and common courtesy at all times. Inappropriate language/behavior/conduct will not be tolerated.
3. Socializing should always be done in public areas.
4. Dress should reflect the values of modesty and respect, and inscriptions and images on clothing should reflect Christian values.
5. The possession or consumption of any alcoholic beverages is prohibited.
6. The possession of any illegal substances is prohibited and subject to legal action.
7. Smoking, vaping, e-cigarettes, smokeless tobacco, and cannabis in any form are prohibited.
8. Weapons and/or drug paraphernalia are prohibited.

I understand and agree to the Code of Behavior. I also understand and agree that at the time of an infraction requiring dismissal, l will be notified and/or I will be responsible for any and all costs related to the participants dismissal from activities and any all costs assessed by local authorities.

MEDICAL PERMISSION FORM

Medical Permission Consent*

Yes, I consent.

I grant permission for the administration of First Aid to my child/children by the people in charge of the event and those transporting my child to and from the event as their judgement deems advisable and to make the necessary referrals to qualified physicians for the treatment of illness or accidents of a more serious nature. I understand I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay of such communication would endanger life. In the case of a medical emergency, I understand that every effort will be made to contatct the parent/guardian of the participant. In the event that I cannot be reached I hereby give permission to the physicians selected by the adult staff to hospitalize, secure proper treatment for and to order injections, anesthesia or surgery if deemed necessary for my child.

MEDICAL INFORMATION

Our Diocese ask for the information below to assure for child(ren) safety when they are in the care of the parish program.

ALLERGIC TO MEDICATIONS:*

Yes. Allergic to medications.
No. Not Allergic to medications.

If YES, please describe:*

Please type NA if not applicable.

ALLERGIC TO OTHER:*

Please type NA if not applicable.

OTHER CONDITIONS:*

Please type NA if not applicable.

MEDICAL INSURANCE INFORMATION

Our Diocese ask for the information below to assure for child safety when they are in the care of the parish program.

Medical Insurance/Policy in the name of:*

Medical Insurance Company*

Policy/Identification Number*

Insurance Company Phone*

Authorized Physician*

Physician Phone*

EMERGENCY CONTACTS

In the event of an emergency please contact:

Information - Emergency Contact 1

Name*

Phone*

Relation*

Information - Emergency Contact 2

Name

Phone

Relation

VBS Fees

VBS Fee*

Families with 1 child/camper ($50.00)
Families with 2 children/campers ($75.00)
Families with 3 or more children/campers ($100.00)

Fees go toward the cost of the magic of VBS such as set designs, and materials for each child, such as, VBS Bible buddies and booklets, Saint holy cards, Imagination Station gizmos, colorful banduras, prepackaged snacks, and the VBS music digital card (one per household), and for picnic food on Friday for the whole family.

After you hit SUBMIT, you will be redirected to the PAYMENT page to make payment by credit/debit card. If you need tuition assistance or would like to submit a check or cash as payment, please contact us at maryjot@olmercy.com THANK YOU!

Please Sign Name Electronically Below*

First Last

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.

VBS 2022 Camper Registration