Daring Disciples Registration Camp and Medical

Daring Disciples Camp & Medical Release
Theme: Miracles

July 20-24 — 9:00 am-12:00 pm

Conotan Learning Center

Cost: $35 first child, $25 for each additional child
Child's Name

First NameMiddle NameLast Name
Child's Preferred Name:
If different than teen's name field...
Child's Gender
Child's Grade in Fall
Child's Birthday

MonthDayYear
Date
Food or Other Allergy (including dietary restrictions)
Chronic Medical Condition (e.g., epilepsy, diabetes, etc.)
Learning Disability
Please let us know if there is anything else we should know about your child...
Would you like to add a second child?

Second Child's Name

First NameMiddle NameLast Name
Second Child's Preferred Name:
If different than teen's name field...
Second Child's Gender
Second Child's Grade in Fall
Second Child's Birthday

MonthDayYear
Date
Food or Other Allergy (including dietary restrictions)
Second Child
Chronic Medical Condition (e.g., epilepsy, diabetes, etc.)
Second Child
Learning Disability
Second Child
Please let us know if there is anything else we should know about your child...
Second Child
Would you like to add a third child?

Third Child's Name

First NameMiddle NameLast Name
Third Child's Preferred Name:
If different than teen's name field...
Third Child's Gender
Third Child's Grade in Fall
Third Child's Birthday

MonthDayYear
Date
Food or Other Allergy (including dietary restrictions)
Third Child
Chronic Medical Condition (e.g., epilepsy, diabetes, etc.)
Third Child
Learning Disability
Third Child
Please let us know if there is anything else we should know about your child...
Third Child
Would you like to add a fourth child?

Fourth Child's Name

First NameMiddle NameLast Name
Fourth Child's Preferred Name:
If different than teen's name field...
Fourth Child's Gender
Fourth Child's Grade in Fall
Fourth Child's Birthday

MonthDayYear
Date
Food or Other Allergy (including dietary restrictions)
Fourth Child
Chronic Medical Condition (e.g., epilepsy, diabetes, etc.)
Fourth Child
Learning Disability
Fourth Child
Please let us know if there is anything else we should know about your child...
Fourth Child
Would you like to add a fifth child?

Fifth Child's Name

First NameMiddle NameLast Name
Fifth Child's Preferred Name:
If different than teen's name field...
Fifth Child's Gender
Fifth Child's Grade
Fifth Child's Birthday

MonthDayYear
Date
Food or Other Allergy (including dietary restrictions)
Fifth Child
Chronic Medical Condition (e.g., epilepsy, diabetes, etc.)
Fifth Child
Learning Disability
Fifth Child
Please let us know if there is anything else we should know about your child...
Fifth Child

* The link for payment will be on the Thank You page once you complete the registration form. Do not let fees stop you from indicating interest. Scholarships are available.

Parent/Guardian Info

There will be an option to add an additional parent at the bottom of the page.
Parent/Guardian's Name

First NameLast Name
Parent/Guardian's Email
example@example.com
Parent/Guardian's Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Type of Primary Phone
Parent/Guardian's Secondary Number
Please enter a valid phone number.Format: (000) 000-0000.
Type of Secondary Phone
Parent/Guardian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like to add information for an additional parent or guardian

Additional Parent/Guardian Info
Parent/Guardian's Name

First NameLast Name
Parent/Guardian's Email (if different from other parent)
example@example.com
Parent/Guardian's Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Type for Primary Phone
Parent/Guardian's Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Type for Secondary Phone
Address (if different from other parent/guardian)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Info
Emergency Contact Name (other than parent/guardian)

First NameLast Name
Emergency Contacts Relation to Child
Emergency Contact's Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Family Doctor / Practice Name

Insurance Information
What parent/guardian is this insurance under?
Medical Insurance Company
Group #
Plan #
I.D. #

Archdiocesan Policy for Youth Activities

This waiver is a form required by the Archdiocese of Cincinnati. It will be required for all Bellarmine Events.
1. I, the custodial parent/legal guardian of __________________________________________ (the “Child”), give permission for my Child to participate in the activity described on the Activity Information Form (the “Activity”) and release from all liability, indemnify, and hold harmless St. Robert Bellarmine Parish (aka Bellarmine Chapel) (“Parish and School”), the Archdiocese of Cincinnati (the “Archdiocese”), the Archbishop of Cincinnati (the “Archbishop”), both individually and as trustee for the Archdiocese, all parishes and schools within the Archdiocese, and all of their agents, representatives, volunteers, and employees from any and all liability, claims, judgments, damages, costs and expenses, including attorneys’ fees, arising out of any injury, illness, infectious and/or communicable disease (such as MRSA, influenza, or COVID-19), or death, (including any injury, illness, infectious and/or communicable disease, or death caused by the negligence of Parish and School, the Archbishop, the Archdiocese, any parish or school within the Archdiocese, or any of their agents, representatives, volunteers, or employees) incurred by my Child while participating in the Activity, traveling to or from the Activity, or while using the facilities and equipment of the Parish and School. I further agree not to bring or prosecute or allow to be brought or prosecuted (including, but not limited to, prosecution through subrogation) in my name, or on behalf of my Child, any claims, lawsuits, or actions against Parish and School, the Archbishop, the Archdiocese, all parishes and schools within the Archdiocese, or their agents, representatives, volunteers, and employees.
2. I understand that my Child’s participation in the Activity is purely voluntary and is a privilege and not a right, and that my Child, and I on behalf of my Child, agree to my Child’s participation in the Activity in spite of the risks of injury, illness, infectious and/or communicable disease (such as MRSA, influenza, or COVID-19), and death. I agree that if my Child has underlying heath concerns which may place him/her at greater risk of contracting COVID-19 or that would possibly increase the severity of illness if COVID-19 is contracted, then my Child and I will consult with a health care professional before participating in the Activity.
3. I agree to instruct my Child to cooperate with the agents of Parish and School and/or the Archdiocese who are in charge of the Activity.
4. I authorize the agents of Parish and School and/or the Archdiocese who are acting as leaders of the Activity to seek medical treatment for my Child in the event of any injury, illness, or medical emergency during the Activity or related travel. I understand that the agents of Parish and School and/or the Archdiocese will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my Child.
5. Please indicate. "I agree" or "I do not agree" that Parish and School and/or the Archdiocese may use my Child’s portrait or photograph for promotional purposes, website, and office functions.
Child's Portrait or Photograph...
6. Please indicate, "I agree" or "I do not agree" that Parish and School and/or the Archdiocese may use social media and technology to communicate with my Child regarding parish/school related ministry activities.
Social Media Use
7. This Permission, Release, and Authorization is intended to be as broad and inclusive as permitted by the law of the State of Ohio, and if any portion hereof is declared invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This Permission, Release, and Authorization shall be construed in accordance with the laws of the State of Ohio, excluding, and irrespective of, any choice of law principles to the contrary.
8. Parish and School, the Archdiocese, the Archbishop and their agents, employees, and volunteers shall have no liability whatsoever in the event the Activity is cancelled due, in whole or in part, to any present or future pandemic, epidemic, widespread disease or illness, public health concern, or circumstances arising therefrom, or from actions taken by any governmental or municipal authority to prevent, avoid, or mitigate the impacts thereof.
I have carefully read and understand and accept the terms and conditions stated herein and I acknowledge and agree that this Permission, Release, and Authorization to Seek Medical Treatment shall be effective and binding upon me, my Child, and our personal representatives, estates, assigns, heirs, and next of kin. I have signed below of my own free will.
By selecting 'I AGREE' above and signing your name here, this counts as a legal signature and acknowledges agreement to the aforementioned terms.
Do you agree with the Archdiocesan Policy for Children's Activities?
Should be Empty:

Parish	Bellarmine Chapel
Program	Daring Disciples Camp
Starting Date	July 20, 2026
Ending Date	July 24, 2026
Registration Fee	$35 first child, $25 additional children*
Usual Location	Xavier University Campus - Conaton Learning Center
Usual Day/Time	Monday - Friday from 9:00 a.m. to Noon
Routine Activities	Activities, Crafts, Music, Prayer
Group Leader Phone	513-202-4070
Other Information	Parking is provided in adjacent lots, drive outisde Conotan reserved for drop off and pick up. Plan to join us for a picnic Fri at 12:00 pm

Daring Disciples Camp & Medical Release

Parent/Guardian Info

Additional Parent/Guardian Info

Emergency Info

Insurance Information

Archdiocesan Policy for Youth Activities

3. I agree to instruct my Child to cooperate with the agents of Parish and School and/or the Archdiocese who are in charge of the Activity.

5. Please indicate. "I agree" or "I do not agree" that Parish and School and/or the Archdiocese may use my Child’s portrait or photograph for promotional purposes, website, and office functions.

6. Please indicate, "I agree" or "I do not agree" that Parish and School and/or the Archdiocese may use social media and technology to communicate with my Child regarding parish/school related ministry activities.

By selecting 'I AGREE' above and signing your name here, this counts as a legal signature and acknowledges agreement to the aforementioned terms.