St. Leo's Little Disciples 2026-2027

Father's Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Mother's Name

First NameLast Name

Mother's address is the same as fathers address.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Alternate contact person if parents are unavailable.

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Relationship to child(ren)

First Child's Name

First NameLast Name

#1 Child's Birth date

# 1 Child's Grade

ALLERGIES: Please list all known allergies, including how you child has been treated and with what medication and frequency.

MEDICATIONS: Please list medications your child is taking and frequency.

MEDICAL CONDITIONS: Please list all known medical conditions including limitations and/or conditions of which we should be aware.

Please indicate.

Second Child's Name

First NameLast Name

#2 Child's Birth date

# 2 Child's Grade

ALLERGIES: Please list all known allergies, including how you child has been treated and with what medication and frequency.

MEDICATIONS: Please list medications your child is taking and frequency.

MEDICAL CONDITIONS: Please list all known medical conditions including limitations and/or conditions of which we should be aware.

Please indicate.

Third Child's Name

First NameLast Name

#3 Child's Birth date

# 3 Child's Grade

ALLERGIES: Please list all known allergies, including how you child has been treated and with what medication and frequency.

MEDICATIONS: Please list medications your child is taking and frequency.

MEDICAL CONDITIONS: Please list all known medical conditions including limitations and/or conditions of which we should be aware.

Please indicate.

Fourth Child's Name

First NameLast Name

# 4 Child's Grade

#4 Child's Birth date

ALLERGIES: Please list all known allergies, including how you child has been treated and with what medication and frequency.

MEDICATIONS: Please list medications your child is taking and frequency.

MEDICAL CONDITIONS: Please list all known medical conditions including limitations and/or conditions of which we should be aware.

Please indicate

Sacramental Prep (2nd - 5th grade)
First Reconciliation and First Communion

My child is in 2nd grade or above and ready to receive his/her sacraments of First Reconciliation and First Communion. Please type your child's name on the line below.
First Name

Which church was your child baptized?

St. Leo's is committed to protecting the privacy, dignity and safety of minors while responsibly using photographs, video recordings or other media images to communicate the mission and ministries of the parish, diocese and schools.

I grant permission to the Diocese of Grand Island, its employees, parish staff, school staff and volunteers, leaders to photograph and/or record my/our son or daughter and to use such images for parish or diocesan or school communications, publicity and marketing. I/We understand that my/our son/daughter will not be identified by full name and that images will be used in a manner consistent with diocesan Safe Environment policies

I hereby warrant to the best of my knowledge; my child(ren) in good health and able to participate in St. Leo's program activities.

I authorize treatment for my minor child(ren) in the event of a medical emergency occurring during my absence. I authorize consent for medical procedures acting on authority of the medical treatment consent form for which medical providers deem necessary for my minor child.

I, the parent/guardian of minor child(ren) release and agree to hold harmless St. Leo's Parish Community, facilitators, chaperones or persons connected with the parish from any liability, claims or damages for personal injury or property loss/damage which may occur during Little Disciple program or youth and family gatherings.

Who is health insurance provided thru

First NameLast Name

Health Insurance Co.

Insurance Policy Number

Signature of Parent/Guardian

Date

St. Leo's Catholic Church

Little Disciples