Childcare Registration

Parent Name*

First Name Last Name

Email*

example@example.com

Cell Phone Number*

Please enter a valid phone number.

Child #1 Name*

First Name Last Name

Age of child*

Child #2 Name

First Name Last Name

Age of child

Child #3 Name

First Name Last Name

Age of child

Child #4 Name

First Name Last Name

Age of child

Any allergies or medical conditions we should know about (please list with name of child):*

Emergency Contact Name*

First Name Last Name

Emergency Contact Number*

Please enter a valid phone number.

WAIVER: As the parent or guardian of this child, I authorize participation in Explorers Childcare Ministry. I assume all risks and hazards incidental to such participation both during an activity and en route and do hereby release and waive all claims against the Diocese of Pensacola -Tallahassee and Saint Mary Church, its staff, volunteers and participants. I also grant permission for emergency first aid to be given in case of injury and transportation to the hospital, if necessary. I have read and agree to the waiver above. Please sign your name electronically below.

By selecting the "I Accept" box, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions.

Electronic Signature Waiver*

I accept

Signature*

Clear

We would like to take photos of your child and make it into booklets for you to keep. We do not plan to post online or publish publicly, but we need to have you sign this waiver for Diocese purposes.

It is the promise and commitment of the Diocese of Pensacola-Tallahassee to use pictures and videos from Diocesan and/or parish youth events in a dignified and respectful manner.

I hereby authorize the Diocese of Pensacola-Tallahassee, including its parishes, schools, and institutions (hereinafter referred to as “Diocese of Pensacola-Tallahassee”) to use, prepare, reproduce, record, video tape, publish, distribute, broadcast, electronically store, and exhibit my name, image, portrait, likeness, words, and/or voice in connection with interviews, sessions, or events conducted, sponsored, or arranged by the Diocese of Pensacola-Tallahassee and its employees, volunteers, and agents. I acknowledge that any notes, photographs, motion pictures, digital images, recordings, or other media format taken of me will become the property of the Diocese of Pensacola-Tallahassee, and I specifically waive any right to compensation for the foregoing. I understand that my likeness, name, image, or voice may be used by the Diocese of Pensacola-Tallahassee without limitation for any professional purpose, now or in the future, and I consent to the same. This permission extends to any authorized print or broadcast media organization that may participate in such preparation, use, reproduction, publication, or distribution.

I release the Diocese of Pensacola-Tallahassee and its employees, volunteers, agents, and designees from liability for any violation of any personal or proprietary right I may have in connection with such use. I also hereby waive any right I may have to inspect and approve in advance the photographs, videos, sound recordings, or publications or media in which I am included. I agree to release the Diocese of Pensacola-Tallahassee and its employees, volunteers, agents and designees from any liability by virtue of the use of the photographs or video recordings, regardless of any blurring, distortion, optical illusion, or alteration which may occur when the photographs or videos are taken, printed, or displayed.

In regard to the media release above:*

I agree to itI do not agree to it

Signature*

Clear

Saint Mary Childcare Registration