Child's Name
Date of Birth
Address
Cell Phone
Grade for 2025-26 Academic Year
School for 2025-26
T-Shirt Size
Parent / Legal Guardian 1 Name
Parent / Legal Guardian 2 Name
Home Phone
Work Phone
Cell Phone
Preferred Contact Email
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship
Health Information: (Are there any allergies or other medical conditions which may affect the participant's involvement in BWE?)
Primary Healthcare Provider
Primary Healthcare Provider Phone
Health Insurance Company
Health Insurance Policy Number
Parent Permission Agreement
As parent/legal guardian of the youth named on this form, I give my permission for him/her to participate fully in St. Luke's BEST WEEK EVER Vacation Bible School from July 13-17,2026 9am-3pm. I agree to indemnify and hereby release the Most Reverend Michael F. Burbidge Bishop of the Catholic Diocese of Arlington and his successors in office, as well as the Catholic Diocese of Arlington and all Diocesan clergy, employees, volunteers, and participating parishes and schools from any and all liability, claims, demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned of the participant resulting from said participant’s involvement in the above mentioned event. Furthermore, I on behalf of the participant hereby assume all risk of personal injury, sickness, death, damage, and expenses resulting from said participant’s involvement in the above described event.
Informed Consent to Medical Treatment
I request that in my absence the above-named minor be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor. I assume full responsibility for all costs of such treatment. Further, should it be necessary for the participant to return home due to medical, disciplinary, or other reasons, I do hereby assume responsibility for the participant’s transportation home and any costs related thereto.
Photo, Press, Audio, and Electronic Media Release
I authorize the Catholic Diocese of Arlington, its parishes, its schools and/or the Arlington Catholic Herald to use and publish my child’s photograph, video and/or audio recording along with their name identifying them for educational, news stories, illustration and/or marketing purposes. Use of electronic communication: I authorize St. Luke’s Youth Ministry and its Volunteers to communicate with the participant through the following electronic means: phone call, email, text messaging, Facebook, and Instagram. This permission is granted with the understanding that communication will take place at reasonable times and in limited durations. Parents/guardians who do not wish to grant this permission should notify St. Luke’s Office of Youth Ministry in writing.
Interested in volunteering? We need a lot of help to make our week successful. Please list the names of anyone interested volunteering, along with their grade level (or if they are an adult, list that).
E-signature (Parent's or legal guardian's signature)
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