St. Thomas Catholic Church
Religious Education Registration 2015-16
Grades: K – 8 only
P.O. Box 3, Underhill Center, Vt. 05490-0003
802-899-4770 / email:
Health / Emergency / Permission Form
Student’s Name: Last ________________ First ________________ M.I. __ Nickname ______________
Birth Date (mm/dd/yy): ___/___/___ Sex ____ Age ____
Parent(s) / Guardian: ____________________________________________________________
Address: ______________________________ Town+Zip _______________________________
Parent’s emergency contact number during Sunday Religious Education______________________
Medical information:
Drug or food allergies ____________________________________
Current Medication / Reason for medication _________________________________________
Special Medical Needs: medical, learning disabilities, physical disabilities: ________________________
I hereby give permission for my child, ______________________________________, to participate in
field trips, retreats or service projects scheduled by the St. Thomas Religious Education Program. I
hereby release and indemnify St. Thomas Church from any and all liability arising from claims of any
kind or nature whatsoever from my child’s participation in these events.
I grant permission for photographs of my child to be used by St. Thomas Church in conjunction with the
Religious Education Program. Uses include, but are not limited to St. Thomas onine illustrations, class
activities, and bulletin board postings located in the church.
In case of a medical emergency, I understand that every effort will be made to contact the parent/guardian
of the participant. In the event that I cannot be reached, and / or a delay in the treatment would endanger
life, I hereby grant permission for the delegated agents of St. Thomas to secure proper treatment for my
son/daughter. I agree to accept any financial responsibility as a result of such treatment.
I specifically waive claim or claims that may be derived from any accident or injury sustained by my son /
daughter en route to any above mentioned activities. I further agree to indemnify and hold harmless St.
Thomas Church, the Diocese of Burlington, their staff and all adult supervisors working on their behalf.
Parent / Guardian Signature ________________________________________ Date _________________