CFF Program Registration, Returning Student

Page 2
Pickup Authorization
In an effort to protect our students, we ask that you let us know, in advance, who has your permission, other than Parents/Legal Guardians, to pick up your child from Children's Faith Formation Classes.

Please list those individuals below:
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to Child or Family*
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Child or Family
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Child or Family
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Child or Family
The information above is correct, and I hereby give permission for my child to be picked up by the individual(s) listed above. I understand that my child will NOT be released to any individual that is not listed on this form.
Parent/Legal Guardian Signature:*

Clear
Printed Name*
Please type your name

Page 3
EMERGENCY INFORMATION:
This information will be extremely important in the event of an accident or medical emergency.
Child's Medical Information:
Primary Doctor:*
Name of Doctor or Practice
Phone Number:*
Office Number
Insurance Plan:
Insurance #:
Group #:
Policy Holder:
Name of Subscriber
*In the case of an emergency, it is imperative that the Children's Faith Formation Office be able to reach the child's Parent/Legal Guardian.

When attempts are not successful, we will need a list of the names of individuals to whom we may contact and release your child if we cannot reach you.
Emergency Contact #1
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to Child or Family*
Emergency Contact #2 (if applicable):
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Child or Family
Emergency Contact #3 (if applicable):
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Child or Family
Please indicate any vital information you think the Children's Faith Formation Office may need to know. This may include special needs (learning, physical, dietary, allergies, etc.) This information will be kept CONFIDENTIAL.
IF YOU NEED FURTHER ASSISTANCE, PLEASE CONTACT MARYALICE HOGAN AT 352-489-3166.
Parent/Legal Guardian Consent And Agreement for Emergencies

As Parent/Legal Guardian, I consent to have my child receive first aid by St. John the Baptist Catholic Church Staff/Catechists and, if necessary, be transported to receive emergency care. I will responsibile for all charges not covered by insurance. I consent that the emergency contact person(s) listed above is/are to be authorized contact with, release of emergency related information, and/or release of my child in the event of illness, evacuation, or other emergency that may occur while my child is attending Children's Faith Formation Classes. I further consent for this/these individual(s) to ACT ON MY BEHALF until I am available.
Parent/Legal Guardian Signature:*

Clear
Printed Name*
Please type your name

Page 4
Photo/Videotape Recording Authorization:
Please choose the options that applies to your child.
My child: May have his/her name published in the newspaper/church bulletin. May have his/her photo published in the newspaper/church bulletin. May have his/her photo posted on St. John's website/Facebook page.*

Yes - agree to allowNo - not agree or allowAdditional comment: __________________________________________________
I hereby expressly assign to the Diocese of Orlando, and to all its agents all the rights, title and interest in, and to all photos/videotape recordings made by such in which my child appears and/or his/her voice is used in and in connection with the videotaping of this event. I hereby authorize the reproduction, sale, lease, copyright, exhibition, broadcast and/or any distribution of said photos/videotape without limitation for any purpose whatsoever; and I further waive all rights to any compensation for my child’s appearance or participation in the photographs/videotape recordings.
Parent/Legal Guardian Signature:*

Clear
Printed Name*
Please type your name

Page 5
CHILDREN'S FAITH FORMATION PROGRAM

2024-2025
My preferred method of communication to receive program news and updates is:*

TextEmailPaper Fliers
I desire that my child participate in the 2024-2025 Children’s Faith Formation Program of St. John the Baptist Catholic Church, Dunnellon, Florida. To the best of my knowledge, the information that I have provided on this registration form is correct.
Parent/Legal Guardian Signature:*

Clear
Printed Name*
Please type your name
Relationship to child*
Date*

MonthDayYear
Date
If you need assistance, please contact MaryAlice Hogan: 352-489-3166.
Once you click SUBMIT, your child's registration will be sent. You will NOT be able to access or make further edits.
Should be Empty:

Photo/Videotape Recording Authorization: