RE/YOUTH REGISTRATION FORM AND CONSENT WAIVERChurch of the Epiphany of the Lord School Year 2021-2022PLEASE FILL OUT ONE FORM FOR EACH CHILDThis Form must be completed and executed for participation in the RE/Youth Activities as a part of registration. Student's Name (First - Middle Initial - Last) Sex GirlBoy Age Grade Birth Date Father's Name Father's Phone Mother's Name Mother's Phone Student resides with please list all that apply (Mother, Father, Gardian(s)) Contact Phone Address/City/State/Zip Home Phone Cell Phone Business Phone Emergency Contact 1 Relationship Home Phone Cell Phone Emergency Contact 2 Relationship Home Phone Cell Phone School Level PreSchoolElementaryMiddle SchoolHigh School School District Archdiocese of Oklahoma CityBethanyCashionCharter SchoolDeer CreekEdmondEl RenoMustangNormanOklahoma CityPiedmontPutnam CitySeminoleWestern HeightsYukonOther Elementary School Attending N/AAngie Debo ElementaryApollo ElementaryArbor Grove ElementaryBethany ElementaryCasady SchoolCashion Elementary SchoolCentral Elementary SchoolCoolidge ElementaryCouncil Grove ElementaryCrossings Christian SchoolDeer Creek ElementaryEpic Charter SchoolHefner Middle SchoolHillcrest ElementaryHoly Trinity Catholic SchoolHome SchoolJames L. Dennis ElementaryLake Park ElementaryLakeview ElementaryNorth Ridge ElementaryNorthern Hills ElementaryNorthwood ElementaryParkland ElementaryPiedmont Early Childhood CtrPiedmont ElementaryPrairie View ElementaryRalph Downs ElementaryRidgeview ElementaryRollingwood ElementaryRose Union ElementarySeton Home SchoolShedeck ElementarySkyview ElementarySpring Creek Mothers Day OutSt. Charles Borromeo SchoolSt. John Nepomuk SchoolStoneridge ElementarySurrey Hills ElementaryTulakes ElementaryTulakes ElementaryWestern Oaks ElementaryWestfield ElementaryWiley Post ElementaryWill Rogers ElementaryOther Middle School Attending N/ABelle Isle Middle SchoolBethany Middle SchoolCanyon Ridge IntermediateCasady SchoolClassen S.A.S. Middle SchoolCrossings Christian SchoolDeer Creek IntermediateDeer Creek Middle SchoolDove Middle SchoolEpic Charter SchoolHefner Middle SchoolHome SchoolIndependence Charter MiddleKenneth Cooper Middle SchoolPiedmont IntermediatePiedmont Middle SchoolSummit Middle SchoolWestern Oaks Middle SchoolYukon Middle SchoolOther High School Attending N/ABethany High SchoolBishop McGuinness High SchoolCasady SchoolClassen S.A.S. High SchoolCristo Rey Catholic High SchoolCrossings Christian SchoolDeer Creek High SchoolEdmond Memorial High SchoolEpic Charter SchoolHarding Chapter Prep H.S.Home SchoolJohn Marshall High SchoolMount Saint Mary High SchoolMustang High SchoolPiedmont High SchoolPutnam City North HighPutnam City West HighYukon High SchoolOther Sacraments Baptism Date and Church First Communion Date and Church Confirmation Date and Church Please Select Class Time Zoom Class: Saturday 10:30amKinder: Sunday 11:15-12:301st Grade: Sunday11:15-12:302nd Grade: Sunday 11:15-12:303rd Grade: Sunday 11:15-12:304th Grade: Sunday 11:15-12:305th Grade: Sunday 11:15-12:30Middle School: Wed 6:30-8:00High School: Sunday 6:30-8:00 PARTICIPATION PERMISSION: I, the undersigned, am custodial parent/legal guardian of Participant and request that he/she be to allowed participate in the RE/Youth programs, events and activities to be held at Epiphany of the Lord Parish during the 2000/2021 school/parish year (the “RE/Youth Activities”). I understand that the RE/Youth Activities consist of weekly sessions and related activities which may be held from time-to-time. I understand and accept this policy LOST OR STOLEN ITEMS: I hereby understand and agree that neither the Archdiocese of Oklahoma City or Epiphany of the Lord Parish nor any of their respective employees, directors, officers, agents, representatives and/or volunteers shall be held liable for any of my or my child’s personal property lost or stolen during participation in the RE/Youth Activities. I understand and accept this policy MEDICAL INFORMATION Is Participant taking any medications OR have any medical conditions (e.g., diabetes, epilepsy, heart conditions, etc.) YesNo If YES, explain below or email additional sheet as needed: Does your child have any allergies? (e.g., insects, hay fever, strawberries, peanuts, etc.) YesNo If YES, explain below or email additional sheet as needed: Does your child have any allergies or adverse reactions to medications? (e.g., penicillin, ibuprofen, acetaminophen, etc.) YesNo If YES, explain below or email additional sheet as needed: Does your child have any disabilities or physical or developmental limitations? YesNo If YES, explain below or email additional sheet as needed: Date of last Tetanus Immunization Participant’s Primary Physician Physician's Telephone Health Plan Carrier Group# Policy# Name of primary insured As a rule, medication will not be administered by RE/Youth Program staff. The exception is an RE/Youth program or activity that includes an extended day or overnight activity. If medication is required a Consent and Waiver Medication Form must be completed prior to the activity. I understand and accept this policy CONSENT TO TREATMENT of participant: I am the custodial parent or legal guardian of Participant. I hereby warrant that to the best of my knowledge, Participant is in good health and physically able to participate in the RE/Youth Activities and I assume all responsibility for the health and physical condition and ability of Participant to so participate. In the event of circumstances that indicate that Participant is in need of immediate medical care, I authorize and give permission for Participant to be transported to a hospital/clinic/medical facility for evaluation and emergency medical or surgical treatment, including any necessary X-ray examination. I authorize any licensed physician or medical center to treat Participant. I accept full responsibility for any medical or hospital bills associated with the care of Participant. I understand and accept this policy LIABILITY WAIVER: In consideration of the arrangement set forth herein, I do on behalf of myself, Participant and our respective heirs, successors, assigns and next of kin, release, waive, hold harmless, defend and covenant NOT TO SUE, Epiphany of the Lord Parish, the Archbishop of the Archdiocese of Oklahoma City, and the Archdiocese of Oklahoma City and each of their respective departments, directors, administrators, teachers, officers, agents, representatives, volunteers and employees from any and all actions, claims, demands or liabilities, including without limitation, those for personal injuries or property damage, that I and/or Participant may suffer due to illness or injury suffered by Participant as a result of, or in connection with, participation in the RE/Youth Activities, including the administration of authorized medications, medical treatment and any consequences that may arise as the result of said treatment, including without limitation, housing, meals and collateral entertainment to the fullest extent permitted by law. I understand and accept this policy CORONAVIRUS/COVID-19: Epiphany of the Lord Catholic Church is beginning the resumption of parish activities. RISKS ASSOCIATED WITH CORONAVIRUS/COVID-19: Coronavirus Disease 2019 (COVID-19) has sickened thousands and killed hundreds in Oklahoma. There is substantial evidence of community spread of COVID-19 throughout Oklahoma and most other states. Epiphany is following guidance from the U.S. Centers for Disease Control and Prevention, the Oklahoma State Department of Health and other agencies, and has implemented social distancing measures, increased hand-washing and other hygienic practices, and frequent cleaning of common surfaces. Despite such precautions, the risks associated with transmission of COVID-19 remain high. Individuals participating in an activity may have traveled from other cities or states to participate. In addition, the nature of some activities makes it impossible to observe all of the recommended precautions all of the time; for example, individuals will not always be six feet apart, surfaces will not always be free of viruses and other infectants, etc. Even where the activity allows social distancing, it will be impossible for the parish to ensure that all participants are observing all the recommended precautions. As a result of participation in parish activities, you or your child will be exposed to the risk of infection of communicable diseases, including COVID-19. Symptoms associated with COVID-19 range from mild to severe, and include fever, cough, difficulty breathing, headache, nausea, severe respiratory distress and death. By participating in parish activities or allowing your child to participate you knowingly and voluntarily assume the risk associated with participation. I understand and accept this policy I certify to you that the information contained herein is true and correct to the best of my knowledge and that I fully understand the terms and legal consequences of my execution of this REGISTRATION CONSENT AND WAIVER FORM FOR RE/YOUTH ACTIVITIES consisting of above form. I understand and accept this policy Custodial Parent/Guardian Name Date ALL PARTICIPANTS FOURTEEN YEARS OF AGE AND OLDER MUST READ AND SIGN THIS STATEMENT: I acknowledge that I agree to conduct myself in a manner consistent with the policies of the Epiphany of the Lord Parish and that failure to do so may result in my being required to leave the RE/Youth Activity, and not being allowed to participate in future programs and activities, at the discretion of the Parish/School. I understand and accept this policy Participant’s Signature Date Church of the Epiphany of the Lord Media Release: The parent or guardian of any participants younger than 18 years of age must execute this form. Parents/guardians may grant or deny permission. I, hereby give permission for my son/daughter to be photographed or videotaped at all Church of the Epiphany of the Lord functions and consent to the use by the Church of the Epiphany of the Lord of any videotapes, photographs, slides, audiotapes or any other visual or audio reproduction produced by the Church and/or the Archdiocese, including my child’s name. I understand that these Materials may be used for promotion activities of the Youth, the Church, and/or Archdiocese which may include recruitment, advocacy, etc. These materials may appear in published materials and may appear on Facebook, Church and/or Archdiocesan websites. I give my consent to any such uses the Church and/or Archdiocese deems appropriate without acknowledgement and without being entitled to remuneration or compensation. I release the Church of the Epiphany of the Lord, the Archbishop of the Oklahoma City and the Archdiocese and the respective employees, staff and volunteers of each, from any and all liabilities or damages incurred in connection with the use of my son/daughter’s picture, name or voice recording as part of, or in connection with, the activities described above or similar activities. Yes I give my permission No I DO NOT give my permission Child's Name Date Parent/Guardian Name Date Send
