K - 5 - Sacred Heart Catholic Church

Parent Name REQUIRED Please fill out this field. Please enter valid data.

Parent Email REQUIRED Please fill out this field. Please enter valid data.

Parent Cell Phone # REQUIRED Please fill out this field. Please enter valid data.

Street Address, City, State, Zip REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact Name (First/Last) - not parent listed above REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact Phone Number REQUIRED Please fill out this field. Please enter valid data.

Health Insurance Company Name REQUIRED Please fill out this field. Please enter valid data.

Health Insurance Policy Holder Name REQUIRED Please fill out this field. Please enter valid data.

Health Insurance Policy/ID number REQUIRED Please fill out this field. Please enter valid data.

Name/s of person/s authorized to pick up your child/ren from the event Please enter valid data.

Child #1 Name (First/Last) Please enter valid data.

Child #1 Age Please enter valid data.

Child #1 Grade entering in Aug 2023 PreK Kindergarten 1st 2nd 3rd 4th 5th 6th

Child #1 Birthdate (month/date/year) Please enter valid data.

Child #1 Allergies/Special Needs Please enter valid data.

Child #2 Name (First/Last) Please enter valid data.

Child #2 Age Please enter valid data.

Child #2 Grade entering in Aug 2023 Pre-K Kindergarten 1st 2nd 3rd 4th 5th 6th

Child #2 Birthdate (month/date/year) Please enter valid data.

Child #2 Allergies/Special Needs Please enter valid data.

Child #3 Name (First/Last) Please enter valid data.

Child #3 Age Please enter valid data.

Child #3 Grade entering in Aug 2023 Pre-K Kindergarten 1st 2nd 3rd 4th 5th 6th

Child #3 Birthdate (month/date/year) Please enter valid data.

Child #3 Allergies/Special Needs Please enter valid data.

Child #4 Name (First/Last) Please enter valid data.

Child #4 Age Please enter valid data.

Child #4 Grade entering in Aug 2023 Pre-K Kindergarten 1st 2nd 3rd 4th 5th 6th

Child #4 Birthdate (month/date/year) Please enter valid data.

Child #4 Allergies/Special Needs Please enter valid data.

Volunteer Name (First/Last) Please enter valid data.

Volunteer Cell Phone # Please enter valid data.

Volunteer Age (if middle/high school) Please enter valid data.

Sacred Heart Permission Slip and Release of Liability

By typing my name below, I agree to the following statements:

I give permission for my child/children to attend Vacation Bible School at Sacred Heart Catholic Church.
I understand that in in the event medical treatment is required, every effort will be made to contact me. However, if I cannot be reached, I give permission to the staff or sponsor to secure the services of a licensed physician or other health care provider to provide the care necessary, including anesthesia, for my child's well-being.
I, the parent or guardian, hereby release the Diocese of Pueblo, Sacred Heart Catholic Church, its staff, and the adult and youth volunteers of the responsibility regarding possible injury, accident, sickness, etc, that might occur during the event. I understand that the organizers are taking reasonable precautions to make this a safe and enjoyable experience.
I understand that if the child is displaying any symptoms of an communicable disease/sickness, the child will not be allowed to attend VBS that day.

Parent Signature (type full name to signify agreement of the above statements) REQUIRED Please fill out this field. Please enter valid data.

Signature Date REQUIRED Please fill out this field. Please enter valid data.

Sacred Heart Catholic Church