Faith Formation Registration Form 2024-2025

Emergency Medical Authorization
Emergency Contacts

In the event a parent or guardian cannot be reached, permission is given to the following people to be contacted or to pick up my child(ren).
Please check here if you authorize the same emergency contacts from page 1 to be contacted to pick up your child or make decision on your behalf, in the event that you cannot be reached. If you do not authorize the same people from page 1, please enter the information of the individuals you so authorize below*

Please use the same contacts from page 1.Please authorize the individuals from page 1, as well as those listed belowI do not authorize the individuals from page 1, and instead authorize the individuals listed below.
Contact 1 Name

First NameLast Name
Relationship to Child
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact 2 Name

First NameLast Name
Relationship to Child
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Consent for Emergency Care

Please only sign either the Grant to Consent, or the Refusal to Consent that follow.

I hereby give consent for the following preferred medical providers and local hospital to be called:*

In the event that reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the above-named doctors, or, in the event that that designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonable accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

Facts concerning my child's medical medical history to which a physician should be alerted:

Signature*

Clear
Today's Date*

MonthDayYear
Date
Refusal of Consent
I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take the following action:
Signature

Clear
Today's Date

MonthDayYear
Date

My Products
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Family Registration Fee$50.00
$50 Fee is waived for all registrations in by August 1st!

1 Child Tuition$82.50

2 or more Children Tuition$142.50

3 or more Children Tuition$197.50

Total $0.00
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Tuition Payment

For your convenience, you can pay tuition online. All online payments will incur a service fee of $2.50. If you would prefer, you may pay by check, made out to Ss. Cosmas and Damian.
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Church of Saints Cosmas and Damian