VBS Camper Registration Parent InformationPrimary Contact Name(Required) First Last Secondary Contact Name First Last Primary Email(Required) Secondary Email Primary Phone(Required)Secondary PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Name(Required) First Last Emergency Contact Relationship to Camper Emergency Contact Phone(Required)Alternate Pickup AdultAlternate Pickup Adult Name First Last Alternate Pickup Adult PhoneRegistration InformationNumber of Siblings Being Registered:(Required) 1 Child: $300 2 Children: $570 3 Children: $810 4 Children: $1,020 AfterCamp Needed?(Required) No, I will pickup at 2pm Yes, until 4pm ($100/child) Yes, until 5:15pm ($175/child) AfterCamp Needed?(Required) No, I will pickup at 2pm Yes, until 4pm ($100/child) Yes, until 5:15pm ($175/child) AfterCamp Needed?(Required) No, I will pickup at 2pm Yes, until 4pm ($100/child) Yes, until 5:15pm ($175/child) AfterCamp Needed?(Required) No, I will pickup at 2pm Yes, until 4pm ($100/child) Yes, until 5:15pm ($175/child) Total The above total amount is due in order to complete your child's VBS Registration. Payment for VBS can be made via our Online Giving Hub or by cash or check at the Parish Office Center. A confirmation email will be sent to you upon the completion of the registration process with this information.1st/Only Camper InformationName(Required) First Last Gender(Required) Male Female Date of Birth(Required) MM slash DD slash YYYY School Child Attends Grade Level(Required)Entering KinderEntering 1st GradeEntering 2nd GradeEntering 3rd GradeEntering 4th GradeEntering 5th GradeEntering 6th GradeAny Known Allergies? Any Medical Concerns or Special Needs? Do you have any friends you would like to be placed with in our small groups? Other Comments:2nd Camper InformationName(Required) First Last Gender(Required) Male Female Date of Birth(Required) MM slash DD slash YYYY School Child Attends Grade Level(Required)Entering KinderEntering 1st GradeEntering 2nd GradeEntering 3rd GradeEntering 4th GradeEntering 5th GradeEntering 6th GradeAny Known Allergies? Any Medical Concerns or Special Needs? Do you have any friends you would like to be placed with in our small groups? Other Comments:3rd Camper InformationName(Required) First Last Gender(Required) Male Female Date of Birth(Required) MM slash DD slash YYYY School Child Attends Grade Level(Required)Entering KinderEntering 1st GradeEntering 2nd GradeEntering 3rd GradeEntering 4th GradeEntering 5th GradeEntering 6th GradeAny Known Allergies? Any Medical Concerns or Special Needs? Do you have any friends you would like to be placed with in our small groups? Other Comments:4th Camper InformationName(Required) First Last Gender(Required) Male Female Date of Birth(Required) MM slash DD slash YYYY School Child Attends Grade Level(Required)Entering KinderEntering 1st GradeEntering 2nd GradeEntering 3rd GradeEntering 4th GradeEntering 5th GradeEntering 6th GradeAny Known Allergies? Any Medical Concerns or Special Needs? Do you have any friends you would like to be placed with in our small groups? Other Comments:Registration ConsentConsent(Required) I agree to register my child(ren) for the COTLF/STS VBS Summer Camp and understand the following.My child has permission to participate in the Church of the Little Flower/St. Theresa School VBS Summer Camp. I understand such an event does involve some element of risk incidental to such participation and I do release and hold harmless the Archdiocese of Miami, Church of the Little Flower and St. Theresa Catholic School, their employees, chaperones, leaders, drivers and/or volunteers. Neither the Archdiocese, Church of the Little Flower, or St. Theresa Catholic School, nor any said persons shall be held financially responsible for any injury, illness, or death incurred as a direct or indirect result of this activity. I understand there is no medical insurance provided by the Church, School or the Archdiocese. In the event of an emergency, I hereby authorize emergency treatment to be administered. I understand that photos will be taken throughout the camp and that pictures in which my child appears may be used on the COTLF or STS webpage, social media platforms, and/or other promotional materials. I also authorize the above mentioned emergency contacts and alternate pickup adults to remove my child from the COTLF/STS campus in the case of emergency, illness, or at the conclusion of each day of camp. Total The above total amount is now due in order to complete your child's VBS Registration. Payment for VBS can be made via our Online Giving Hub or by cash or check at the Parish Office Center. A confirmation email will be sent to you upon the completion of the registration process with this information.CAPTCHANameThis field is for validation purposes and should be left unchanged. Share This To:
