2021 VOCATIONS EVENT REGISTRATION

Question Title

* Participant's Information

Last Name

First Name

Address

Address 2

City/Town

ZIP/Postal Code

Parish

Email Address

Phone Number

Question Title

* Which event would you like to attend?

Question Title

* Camper's Date of Birth

Date of Birth

Date

Question Title

* Age

Question Title

* Participant's Grade (2020-21 school year)

7th

8th

9th

10th

11th

12th

Other

Question Title

* Any medical needs? (i.e. medications, allergies, etc.)

Question Title

* Any dietary needs?

Question Title

* T-Shirt Size (Adult Sizes)

Small

Medium

Large

X-Large

XX-Large

NOTE: T-shirts are for camps only!

Question Title

* Parent/Guardian Information

Last Name

First Name

Address

Address 2

City/Town

ZIP/Postal Code

Phone Number

Email Address

Cell Phone

EMERGENCY MEDICAL AUTHORIZATION (Part 1 OR Part II MUST BE COMPLETED)

The purpose of this form is to enable parents and/or guardians to authorize the provision of emergency treatment for the above named participant who becomes ill or injured during an event when parents and/or guardians cannot be reached.

Part 1 - To Grant Consent

In the event reasonable attempts to contact me at the above listed phone numbers have been unsuccessful, I hereby give my consent for:

1. The administration of any treatment deemed necessary by:

Question Title

* Name of Preferred Physician

Name

Company

Phone Number

Question Title

* Name of Preferred Dentist

Name

Company

Phone Number

or in the event the designated preferred practitioner is unavailable, by another licensed physician or dentist.

2. Transfer participant to:

Question Title

* Preferred hospital or any hospital reasonably accessible

Question Title

* This authorization DOES NOT cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

List participant's medical history (include allergies, medications, any physical impairments, etc.) to which a physician and event personnel should be alerted to:

Question Title

* Signature of Parent and/or Guardian (Typed name authorizes the Diocese of Saint Cloud to provide any emergency medical treatment necessary.)

Question Title

* Date

Date

Part II - Refusal of Consent

Question Title

* I DO NOT give my consent for emergency medical treatment of the participant and I wish the authorities to take no action. In the event of illness or injury requiring emergency treatment, I wish the authorities to . . . (Please explain what action you want supervising personnel to take):

Question Title

* Signature of Parent and/or Guardian (Typed name states the Diocese of Saint Cloud will take no emergency action.)

Question Title

* Date

Date