TOTUS TUUS REGISTRATION FORM
Name of Parents/Guardians:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Home Phone:
Format: (000) 000-0000.
Cell Phone:
*
Format: (000) 000-0000.
Alt. Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Child #1
Name
First Name
Last Name
Grade Entering in the Fall
Allergies, medications, medical conditions we should be aware of
Comments
T-shirt Size (Optional) *There is an additional fee for a shirt
Youth Small
Youth Medium
Youth Large
Youth X-Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Child #2
Name
First Name
Last Name
Grade Entering in the Fall
Allergies, medications, medical conditions we should be aware of
Comments
T-shirt Size (Optional) *There is an additional fee for a shirt
Youth Small
Youth Medium
Youth Large
Youth X-Large
Adult SmallType option 5
Adult Medium
Adult Large
Adult X- Large
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Child #3
Name
First Name
Last Name
Grade Entering in the Fall
Allergies, medications, medical conditions we should be aware of
Comments
T-shirt Size (Optional) *There is an additional fee for a shirt
Youth Small
Youth Medium
Youth Large
Youth X-Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Child #4
Name
First Name
Last Name
Grade Entering in the Fall
Allergies, medications, medical conditions we should be aware of
Comments
T-shirt Size (Optional) *There is an additional fee for a shirt
Youth Small
Youth Medium
Youth Large
Youth X-Large
Adult SmallType option 5
Adult Medium
Adult Large
Adult X-Large
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Adult Volunteer #1
Name
First Name
Last Name
Able to assist on the following days
Program Type
Day Program
Evening Program
Days of the week available
Time available
T-shirt Size (Optional) *There is a fee for shirt
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
Adult XXX-Large
Adult Volunteer #2
Name
First Name
Last Name
Able to assist on the following days
Program Type
Day Program
Evening Program
Days of the week available
Time available
T-shirt Size (Optional) *There is a fee for a shirt
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
Adult XXX-Large
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ADDITIONAL EMERGENCY CONTACT INFORMATION: Name and phone number of an adult to reach in the event the parents/guardians listed above cannot be reached.
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Family Physician
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Insurance Company
Policy #
Medical Authorization:
I understand that the Catholic Diocese of Wichita and Totus Tuus assume no responsibility for accidents which may occur in association with diocesan events and activities. I agree to use my/our personal insurance to cover any such incidents. I understand that, in the event medical intervention is needed, every attempt will be made to contact the persons listed above. In the event those individuals cannot be reached, I/We hereby give permission to the physician or any other qualified medical staff selected by the event leader to hospitalize, secure medical treatment, and/or order injection, anesthesia, or surgery for Participant as deemed necessary.
*
I Agree
Permission for Other Medical Matters:
In the event it comes to the attention of the Diocesan and/or parish chaperones that my child complains of illness, I grant permission for non-prescription medication (such as Tylenol, lozenges, etc.) to be given to Participant.
Grant permission for non-prescription medication?
*
Yes
No
Release of Liability for Youth and Adults:
I understand all reasonable safety precautions will be taken at all times by the Catholic Diocese of Wichita and Totus Tuus and its employees and agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree to indemnify and hold harmless the Catholic Diocese of Wichita and Totus Tuus, its leaders, employees and volunteer staff from any and all claims arising from or in connection with attending this event.
*
I understand
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Code of Behavior for Youth and Adults:
I agree to abide by and/or instruct my child to abide by all rules and regulations as outlined by the aforementioned chaperones/representatives. I agree that if I/Participant fail(s) to abide in any way by the rules, that I/Participant can be dismissed from the event and sent home immediately at my/Participant's expense with no right of reimbursement or refund for any amount in connection therewith from the Catholic Diocese of Wichita or its chaperones/representatives.
*
I agree
Photo Release:
I hereby authorize the Catholic Diocese of Wichita and Totus Tuus and its agents to utilize photographic and/or video images of me or my child by the Catholic Diocese of Wichita. In giving my consent, I hereby indemnify and hold harmless the Catholic Diocese of Wichita and Totus Tuus and its agents from any all responsibility of liability. I understand that I will receive no compensation should any photograph and/or video of me or my child be used.
Photo Release Consent
*
Yes
No
By typing your name below, you will be providing an electronic signature
Parent/Guardian's Name
*
First Name
Last Name
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