Summer Service Days

PARTICIPANT INFORMATION

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

In the fall of 2020, I will be entering REQUIRED Please fill out this field.

PARENT/GUARDIAN INFORMATION

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

I am interesting as chaperoning REQUIRED Yes No Please fill out this field.

If you are interested in Chaperoning: REQUIRED I have completed Protecting God's Children I plan on completing Protecting God's Children I have not completed Protecting God's Children Please fill out this field.

I want to participate with Summer Service Days on REQUIRED Friday Saturday Sunday Please fill out this field.

MEDIA WAIVER

I grant permission to use my or my child’s image, name, recording, or academic work in communications that include, but are not limited to, parish bulletin, school newsletter, student newspaper, admission videos, parish/school website and social media.

Please Check: REQUIRED Yes No Please fill out this field.

I grant permission to use my or my child’s image, name, recording, or academic work in communications that include, but are not limited to, archstl.org, St. Louis Review, Catholic St. Louis magazine, archdiocesan social media, The e-Vangelizer (newsletter published by the Catholic Education Office) and any publication(s) by agencies administered by the Archdiocese of St. Louis.

Please Check: REQUIRED Yes No Please fill out this field.

I grant permission to use my or my child’s image, name, recording, or academic work in websites, videos, and publications created by independent foundations and corporations that support Catholic education but are not legally connected to the Archdiocese of St. Louis, including, but not limited to, Today and Tomorrow Educational Foundation, Roman Catholic Foundation of Eastern Missouri, Access Academies, English Tutoring Project, and United Way.

Please Check: REQUIRED Yes No Please fill out this field.

I grant permission to use my or my child’s image, name, recording, or academic work in secular media communications including, but not limited to, print, radio, TV and internet (Examples: St. Louis Post-Dispatch, KMOX radio, and KSDK-TV).

Please Check: REQUIRED Yes No Please fill out this field.

AGREEMENT

1. As the parent or guardian of the above named child, I hereby state that the information included in this form is correct and give permission for my child to participate in Totus Tuus.
   2. I understand that my child will be under the supervision of the Archdiocese of St. Louis Totus Tuus team, Sacred Heart Church staff and volunteers.
   3. I recognize that there are risks inherent in participation in any activity and will not hold the Archdiocese of St. Louis, Sacred Heart Church, its affiliates and their employees, volunteers and agents, responsible for any injury to my child or damage to, or loss of, personal property of my child not caused by the negligence or misconduct of Sacred Heart Church, its affiliates and their employees, volunteers and agents.
   4. In the case of a medical emergency, in the event that I cannot be reached, I hereby give permission for my child to be evaluated, diagnosed and treated in accordance with standard medical practice by licensed medical personnel.
   5. I understand that for all Sacred Heart Youth Ministry activities there is a zero tolerance policy for the use of any mood-altering chemicals (including alcohol and illegal drugs), foul language, threats or any type of abuse and inappropriate physical contact.

By my electronic signature, I, as parent/legal guardian, agree to the above stated Agreement. (Please type in your full name.) REQUIRED Please fill out this field. Please enter valid data.