St. Leo's Catholic Church
2026-2027
Little Disciples
Kindergarten thru 5th grade
Father's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Mother's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / 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 Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to child(ren)
*
First Child's Name
*
First Name
Last Name
#1 Child's Birth date
*
# 1 Child's Grade
*
ALLERGIES: Pleas 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.
*
I DO give permission for minor child to be given over the counter medications such as Tylenol, tums or Ibuprofen.
I DO NOT give permission for minor child to be given over the counter mecications.
Second Child's Name
First Name
Last Name
#2 Child's Birth date
# 2 Child's Grade
ALLERGIES: Pleas 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.
I DO give permission for minor child to be given over the counter medications such as Tylenol, tums and Ibuprofen.
I DO NOT give permission for minor child to be given over the counter medications.
Third Child's Name
First Name
Last Name
#3 Child's Birth date
# 3 Child's Grade
ALLERGIES: Pleas 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.
I DO give permission for minor child to be given over the counter medications such as Tylenol, tums and Ibuprofen.
I DO NOT give permission for minor child to be given over the counter mecications.
Fourth Child's Name
First Name
Last Name
# 4 Child's Grade
#4 Child's Birth date
ALLERGIES: Pleas 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
I DO give permission for minor child to be given over the counter medications such as Tylenol, tums, Ibuprofen.
I DO NOT give permission for minor child to be given over the counter mecications.
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.
*
AGREE
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 AGREE
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.
*
I AGREE
I give permission for St. Leo's parish community to use photos or videos of my child(ren) taken during program activities for St. Leo's promotional purposes on the web page and in the media
*
I AGREE
I DO NOT give permission for my child to be in photos or videos during parish activities.
Who is health insurance provided thru
*
First Name
Last Name
Health Insurance Co.
*
Insurance Policy Number
*
Signature of Parent/Guardian
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: