Youth Programs – Epiphany of the Lord Catholic Parish

Summer Youth Program: Totus Tuus

Totus Tuus Registration 2022 (week of June 26-July 1)

Parish of registration
Parent 1 Name*
First Last
Parent 1 Cell*
Parent 1 Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Parent 2 Name
First Last
Address for Parent 2 (if different from Parent 1)
Street Address City State / Province / Region ZIP / Postal Code
Parent 2 Cell
Parent 2 Email
Emergency Contact Name (other than parent)*
First Last
Emergency Contact Phone Number*
Preferred Hospital*
Doctor*
Doctor's Phone*
Dentist*
Dentist's Phone*
Child 1 Name*
First Last
Child 1 Birthdate*
Month
Day
Year
Child 1 Gender*
Child 1 Grade Level (2022-23 school year)*
Which sacraments has Child 1 received (check all that apply)?*
- Select All
- Baptism
- First Holy Communion
- Confirmation
Please list any/all allergies, health information, and/or learning struggles we need to know about Child 1 in order to best serve him/her.*
Child 2 Name
First Last
Child 2 Birthdate
Month
Day
Year
Child 2 Gender
Child 2 Grade Level (2022-23 school year)
Which sacraments has Child 2 received (check all that apply)?
- Select All
- Baptism
- First Holy Communion
- Confirmation
Please list any/all allergies, health information, and/or learning struggles we need to know about Child 2 in order to best serve him/her.
Child 3 Name
First Last
Child 3 Birthdate
Month
Day
Year
Child 3 Gender
Child 3 Grade Level (2022-23 school year)
Which sacraments has Child 3 received (check all that apply)?
- Select All
- Baptism
- First Holy Communion
- Confirmation
Please list any/all allergies, health information, and/or learning struggles we need to know about Child 3 in order to best serve him/her.
Child 4 Name
First Last
Child 4 Birthdate
Month
Day
Year
Child 4 Gender
Child 4 Grade Level (2022-23 school year)
Which sacraments has Child 4 received (check all that apply)?
- Select All
- Baptism
- First Holy Communion
- Confirmation
Please list any/all allergies, health information, and/or learning struggles we need to know about Child 4 in order to best serve him/her.
Child 5 Name
First Last
Child 5 Birthdate
Month
Day
Year
Child 5 Gender
Child 5 Grade Level (2022-23 school year)
Which sacraments has Child 5 received (check all that apply)?
- Select All
- Baptism
- First Holy Communion
- Confirmation
Please list any/all allergies, health information, and/or learning struggles we need to know about Child 5 in order to best serve him/her.
Child 6 Name
First Last
Child 6 Birthdate
Month
Day
Year
Child 6 Gender
Child 6 Grade Level (2022-23 school year)
Which sacraments has Child 6 received (check all that apply)?
- Select All
- Baptism
- First Holy Communion
- Confirmation
Please list any/all allergies, health information, and/or learning struggles we need to know about Child 6 in order to best serve him/her.
Are there any additional family needs or concerns you'd like us to know about?*
Is there a parent, grandparent, and/or 7th-12th grade student interested in helping with the M-F day program?*
If yes/maybe, please provide name, email, and phone number of potential volunteer.
Consent*
I agree to consent for medical treatment for all of the above-named youth.
If unable to reach parent or guardian, I hereby give my consent for 1) the administration of any treatment deemed necessary by the doctor or dentist listed on the reverse of this form. In the event that the designated practitioner is not available another licensed physician or dentist and 2) the transfer of the player to (hospital) or any hospital reasonably accessible. This authorization does not cover surgery unless the medical opinions of two other licensed physicians or dentists concurring in the surgery are obtained prior to the performance of such surgery.
Liability*
I agree to the liability policy
As the parent or lawful guardian of above named child(ren) give permission for the above-named to participate in Totus Tuus and release from all liability and indemnify Diocese of Toledo, the Bishop of Toledo, both individually and as trustee for the Diocese, and all parishes and schools within the Diocese, and their respective officers, agents, representatives, volunteers, and employees from any and all liability, claims, judgments, cost and expenses, including attorneys’ fees, arising out of any injury or illness incurred by my child while participating in or traveling to or from Totus Tuus and 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 the above named, any claims, lawsuits or actions against the Bishop, the Diocese, and their respective officers, agents, representatives, volunteers and employees.
I further understand that my Child’s participation in Totus Tuus is purely voluntary and is a privilege and not a right, and that the above-named, and I on behalf the above-named, agree to the above-named’s participation in Totus Tuus in spite of the risks.I agree to instruct my child to cooperate with the Bishop or his agents in charge of the activity.

I agree that the Bishop or his agents may use the above-named’s portrait, photograph or video for promotional purposes, website and office functions and use social media and technology to communicate to my child regarding ministry related activities.
This acknowledgement and release 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 acknowledgement and release shall be construed in accordance with the laws of the State of Ohio, except for the choice of law provisions thereof.
I have carefully read and understand and accept the terms and conditions stated herein and acknowledge that this Permission, Release and Liability shall be effective and binding upon me, my above named child(ren) and my own and my Child(ren)’s personal representative or estate, assigns, heirs, and next of kin and that I have signed this agreement of my own free will.
Signature of Parent/Guardian*
Please ensure that all required fields (marked with a star) are filled out. If you hit submit and were not redirected to a new page, please scroll to the top of the form to see which areas you may have missed.

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Summer Youth Program: Totus Tuus

Totus Tuus Registration 2022 (week of June 26-July 1)

Please ensure that all required fields (marked with a star) are filled out. If you hit submit and were not redirected to a new page, please scroll to the top of the form to see which areas you may have missed.