VBS/ Totus Tuus Registration 2022
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Email *
Last Name:
First Name
Gender:
Clear selection
Date of Birth
MM
/
DD
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YYYY
Complete Address:
Home Phone:
Cell:
 E-mail:
Age at time of event:
Grade entering in fall of 2022
Parent/Guardian Name:
Relationship:
Parent/Guardian Home Phone
Work:
 Cell:
Event:
Clear selection
Dates:
Location:
Mode(s) of Transportation:
Parish/School Name & City
Parish/School Group Leader:
DOW-R PARENTAL CONSENT/LIABILITY WAIVER/MEDICAL RELEASE
I agree on behalf of myself, my child named herein, or our heirs, successors, and
assigns, to hold harmless and defend the above named parish/school, its officers, directors, employees and agents, and
the Diocese of Winona-Rochester, its employees and agents, chaperones, or representatives associated with the event,
from any claim arising from or in connection with my child attending the event or in connection with any illness or injury
(including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish/school, its
officers, directors and agents, and the Diocese of Winona-Rochester, its employees and agents and chaperones, or
representative associated with the event for reasonable attorney’s fees and expenses which may incur in any action
brought against them as a result of such injury or damage, unless such claim arises from the negligence of the
parish/school or the Diocese of Winona-Rochester.

IMAGE WAIVER:
 I understand and agree that any photograph, video and internet site image of me or child during this event may be used for promotional purposes.
EMERGENCY MEDICAL TREATMENT:
In the event of an emergency, I give permission for myself or my child to be transported to a hospital for medical treatment. I wish to be advised prior to any further treatment by a doctor or hospital. For myself, in the event that I should require medical treatment and I am not able to communicate my desires to attending physicians/medical personnel, I give permission for the necessary emergency treatment to be administered. I agree to pay the cost of medical treatment in connection therewith, and agree to compensate the parish and the Diocese of Winona-Rochester for expenses incurred.
EMERGENCY CONTACT:
In the event of any emergency, if you are unable to reach me at the above numbers, contact:
Alternative contact name (printed)
Relationship
Home Phone
Work Phone
Cell Phone
Medication my child is taking at present:
My child will bring all such medications necessary, and such medications will be well-labeled and in original containers. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage is as follows:
Family Health Plan Carrier
Policy #:
Family Doctor
Clinic
Phone Number
The undersigned parent/guardian hereby consents that the Diocese of Winona-Rochester be permitted to use and publish for advertising, commercial or publicity purposes, the photograph or video of my child for lawful purpose and the undersigned parent guardian does hereby release the Diocese of Winona-Rochester from any liability in connection with such use.
Student signature (Type your full name)
Date:
MM
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DD
/
YYYY
As Parent or Guardian, I agree to all of the above stated considerations and conditions.
Parent's signature (Type your full name)
Date:
MM
/
DD
/
YYYY
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