HSYM Online Registration

Emergency Contact Information (Other than parent/guardians)

Emergency Contact Name #1*

First Last

Emergency Contact #1 Phone*

Emergency Contact #1 Relationship to Student*

Emergency Contact Name #2*

First Last

Emergency Contact #2 Phone*

Emergency Contact #2 Relationship to Student*

Do you authorize the adult leader to authorize medical treatment for your child in an emergency, as considered necessary by the attending physician?*

Yes
No

If no, state any reasons why you do not want medical care given to your child in an emergency:

Family Physician Name*

Family Physician Address*

Street Address City State ZIP Code

Family Physician Phone*

Medical Insurance Name*

Member ID Number

Group Number

Plan Number*

Parental Permission & Acknowledgement of Conditions for Participation in Program*

1. I/we, parent(s) or authorized guardian(s) give permission for this student to participate in Faith Formation. 2. I/we agree to direct my/our child to cooperate and comply with reasonable direction and instructions from Holy Spirit Staff, adult volunteer leaders and youth volunteers. 3. I/we agree to be responsible for all medical expenses relating to injury of my/our child as a result of his/her participation in these event(s), whether or not caused by the negligence of parish Faith Formation program employees, agents or volunteers or other participants. 4. I/we understand that youth participating in Faith Formation Program events risk injury to the body, psyche or property damage to themselves and others. Such injuries can be caused by other persons or accidentally or intentionally self inflicted, faulty equipment or facilities, conditions of recreational facilities, vehicle accidents while in transport or through the activity itself.

Yes
No

Release & Waiver of Liability & Indemnity Agreement*

In consideration for being permitted to participate in this Faith Formation Program event, use the equipment provided and to enter the premises or facilities of the Diocese of Oakland (Diocese) for any purpose including observation and participation in activities, the parent or guardian for him or herself and any successors in interest and on behalf of the minor child agrees: 1. To release, waive, discharge and promise not to sue the Diocese of Oakland, and its affiliated entities, its officers, directors, employees, agents and volunteers (hereafter referred to as "Releasees") from all liability for any loss or damage, and any claim or demands therefor on account of serious or mortal injury to the body, injury to psyche or property of the minor child, or undersigned parent or guardian, whether caused by negligence or other conduct by the Releases while the minor child, parent or guardian is participating in this event or in, upon or about the premises of the Diocese or any of its facilities or equipment. 2. To indemnify and hold harmless the Releasees eases from any loss, liability, damage or cost it may incur due to the presence of the minor child, parent or guardian in, upon or about the premises of the Diocese, its facilities or equipment, or while participating in any Faith Formation Program whether caused by the negligence of Releasees or otherwise. 3. That the parent or guardian has read this Agreement, voluntarily signs the Agreement and that no oral representations, statements or inducements apart from the contents of this written Agreement have been made.

Yes
No

Model Release Statement*

I give permission for my child named on this form to be photographed and/or videotaped during Faith Formation Activities and events; and for the resulting photographs and/or videotaped footage to be edited, if necessary, and be published and/or broadcast (newspaper, church bulletin, church website, etc) for the purpose of promoting the activities of Holy Spirit Catholic Church.

Grant
Decline

Evacuation Form

In the event of an emergency, no individual telephone communications will be possible. The evacuation plans will go into effect, but you may indicate a preference for your child. The authorities will designate possible types of evacuation in the case of emergency: 1. ON SITE- children will be kept at HOLY SPIRIT under supervision. “Housing”, food and care will be provided here. 2. OFF CAMPUS- dependent upon the situation, children would be assigned to a location by local authorities. Radio stations, air patrol and/or police would be the source of information.

Please list Children Enrolled in Holy Spirit Faith Formaton

In the event of evacuation of Holy Spirit Faith Formation, I choose the following: (please check all that apply)*

I will pick up my children at the evacuation site
I give permission for my children to walk home unattended to a reunion parent.
If I do not pick my children up personally, I designate the following person(s) to act on my behalf.

Name of first person designated to act on my behalf

First Last

Address of first person to act on my behalf

Street Address City State ZIP Code

Phone of first person to act on my behalf

Name of second person to act on my behalf

First Last

Address of second person to act on my behalf

Street Address Address Line 2 City State ZIP Code

Phone of second person to act on my behalf

If, at the time of an emergency, first aid should be administered, I authorize the following: (check ALL that aply)*

First Aid may be administered by a qualified person.
I authorize sending my child to a hospital, if necessary.

HSYM Online Registration

High School Confirmation Registration Form

Student Information

Parents Information

Emergency Contact Information (Other than parent/guardians)