St.

Michael Parish 2013-2014 CCD Registration Form

Parents or Primary Guardian ________________________________________ Cell # __________________________
Mailing Address ____________________________________________________________________________
Primary Email ____________________________________________________________ Home # ________________________


Grade

1st Childs First Name

Last Name

Date of Birth

Sex
Male Female
Medical information, special learning/physical needs
Grade 2
nd
Childs First Name Last Name Date of Birth Sex
Male Female
Medical information, special learning/physical needs
Grade

3rd Childs First Name

Last Name

Date of Birth

Sex
Male Female
Medical information, special learning/physical needs
Grade 4
th
Childs First Name Last Name Date of Birth Sex
Male Female
Medical information, special learning/physical needs
Grade

5
th
Childs First Name

Last Name

Date of Birth

Sex
Male Female
Medical information, special learning/physical needs
Grade 6
th
Childs First Name Last Name Date of Birth Sex
Male Female
Medical information, special learning/physical needs


Gr. K-12 Registration fees: 1 child $60 total 2 children $110 total 3 children $150 total 4 or more children $180 total
Preschool & Confirmation: Preschool child $20 Freshman Confirmation student $15 additional Total Enclosed $______
Registration fees & forms due July 31, 2013. Make checks payable to St. Michael Church. Mail to PO Box 7, Ft. Loramie, OH
45845; drop off at CCD office; put in collection basket marked CCD or bring forms to family night of Vacation Bible School.

If payment cannot be made at time of registration, submit registration form by 7/31/13 and a bill will be sent at a later date.

Volunteers are needed to help in any of the following activities:
4
th
Grade Field Trip to Relic Chapel (4-28-13, 3-5 pm) Will help as youth ministry chaperone when available. Call me.
6
th
Grade Field Trip to Elmwood (date, 3-5 pm) High School World Youth Day-Chaperone (10/16/13, 7-8:30 pm)
Set up for Gr. 2 Parent Mtg. (10-23-13, 9:30-10 am) Baked goods for Liberty Days, July, 2014
Set up for Gr. 2 Parent Mtg. (3-23-14, 9:30-10 am) Baked goods for Lake Loramie Festival, Sept., 2013
Confirmation Retreat Drivers (3-23-14, 9:30 am-3:30 pm) 7
th
& 8
th
Grade Spiritual Survivor Chaperone (4/16/14, 6-8:30 pm)
Christmas Caroling Chaperone (12-18-13, 6-9 pm) HS Lock-In chaperone (1-19-14, 6 pm 5 am)

COMPLETE AND SIGN MEDICAL POA ON REVERSE SIDE
Office Use Only: Full Payment Received Partial Payment of $____ Received Balance due payment of $___Received

ARCHDIOCESE OF CINCINNATI

Permission, Release and Medical Power of Attorney

1. I, the lawful parent or guardian of the child/children listed on previous page give permission for my child/children to
participate in the activity described on the reverse and release from all liability and indemnify the Archbishop of Cincinnati (the
Archbishop), both individually and as trustee for the Archdiocese of Cincinnati and all parishes within the Archdiocese, and their
officers, agents, representatives, volunteers, and employees from any and all liability, claims, judgments, cost or expenses, including
attorney fees, arising out of any injury or illness incurred by my child/children while participating in or traveling to or from the activity.
2. I agree to instruct my child/children to cooperate with the Archbishop or his agents in charge of the activity.
3a. I appoint the Archbishop or his agents who are acting as leaders of the activity as my attorney in fact to act for me in my
name and my behalf, in any way that I would act if I were personally present, with respect to the following matters if any injury, illness
or medical emergency occurs during the activity or related travel:
(i) To give any and all consents and authorizations to any physicians, dentist, hospital or other persons or institutions
pertaining to any emergency medications, medical or dental treatments, diagnostic or surgical procedures or any other
emergency actions as our attorney shall deem necessary or appropriate for the best interest of the child/children.
(ii) I understand that the agents of the Archbishop will make a reasonable attempt to contact me as soon as possible in the
event of a medical emergency involving my child/children.
3b. This power of attorney shall lapse automatically upon completion of the activity and related travel.
4. I agree that the Archbishop or his agents may use my child/childrens portrait or photograph for promotional purposes and
office functions.
I have carefully read this statement, and my signature acknowledges that I fully understand the content and meaning.

Signature of Parent or Guardian_____________________________________________ Date _____________


Insurance information for the child/children listed on other side of this form

Medical Insurance Co. ________________________________________________________________________

Policy or Group # ______________________________ Policy Holders Name __________________________

Insurance Phone# _____________________________

Family Physician ______________________________ Physician Ph # ________________________________




ACTIVITY INFORMATION
Ongoing Activities

Church Agency: St Michael Church Emergency #: 937-295-2891 or 937-295-2179
Location: St. Michael Church, St. Mikes Place, St. Michael Hall & Ft. Loramie High School(Wednesday evenings only)
Starting Date/Time: 08/01/13 - various starting times Ending Date/Time: 08/01/14 various ending times
Activities Involved: All regularly scheduled CCD and Youth Ministry activities
Type of Transportation (if any): Provided as necessary
Group Leaders Info: Diane Seger for preschool, kindergarten & elementary CCD, dianes@nflregion.org, office # 937-
295-2179 or cell # 937-726-6525; Kate Boeke for Jr. High/Sr. High CCD, kateb@nflregion.org, office # 937-295-2179;
Kevin Musser for Jr. High/Sr. High Youth Ministry, kevinm@nflregion.org, office # 937-295-2891 or cell # 937-726-1295
Other Information: This Medical Release Form will be used for all CCD classes and events along with any CYM
events your child/children may attend.