Totus Tuus Student Registration

Student Name

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Date of Birth REQUIRED Please fill out this field. Please enter a date.

Grade Entering Fall 2019 REQUIRED Please fill out this field. Please enter valid data.

Parent/Guardian Name

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Street Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Parent Email REQUIRED Please fill out this field. Please enter an email address.

Parent Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Emergency Contact

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Name of Family Physician REQUIRED Please fill out this field. Please enter valid data.

Physician Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Insurance Company REQUIRED Please fill out this field. Please enter valid data.

Policy # REQUIRED Please fill out this field. Please enter valid data.

Allergies, Medicines or Medical Conditions

RELEASE OF LIABILITY - I grant permission for my child to attend the Totus Tuus Summer Program at St. Anthony's and hereby authorize the adult(s) representing St. Anthony as my agents, to consent in case of a medical emergency to any examinations, x-rays, anesthetic, medical, or surgical diagnosis or treatment and hospital care deemed advisable by a qualified physician or local hospital. An authorized parish adult agrees to contact the undersigned as possible if an emergency should arise. I will assume responsibility for fees incurred by such an emergency. In addition, I certify that the above information is correct and give permission for the release of medical records to the attending physician. I realize that I cannot hold Totus Tuus staff, Totus Tuus volunteers, St. Anthony Parish, St. Anthony School, nor the Archdiocese of Indianapolis responsible for any such emergency.

MEDICAL AUTHORIZATION - I understand that the Catholic Diocese of Indianapolis 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.

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.

RELEASE OF LIABILITY FOR YOUTH AND ADULTS - I understand all reasonable safety precautions will be taken at all times by the Catholic Diocese of Indianapolis 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 and Totus Tuus, its leaders, employees and volunteer staff from any and all claims arising from or in connection with attending this event.

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 Indianapolis or its chaperones/representatives.

I Agree to all of the above Please select this field.

Permission to use photographs of your child
As a parent or guardian of the above named child, I herby give permission for photographs taken during VBS events to be used on our social media and/or Parish website to promote Youth Ministry for St. Anthony Parish.

Please check the YES box below if you agree.

If you DO NOT wish to have your child’s photographs published,
please check the DENIED box below.

Please check one box: REQUIRED YES, you may use photographs of my child. DENIED, do not use photographs of my child. Please fill out this field.

The cost for Totus Tuus is $20 per Family/Individual I will make my payment online I will send my payment into the Parish Office