ST. BENEDICT'S Catholic Summer Camp 2022 - Participants
The Travels of St. Paul

Who: 3.5 years old (must be potty trained) through rising 4th
Event Dates: July 18-22
Event Times:  9am - 12pm
Event Address: St. Anselm Hall St. Benedict School 3100 Grove Ave, Richmond VA 23221
Contact us at (804) 254 - 8810 x 109 or
Cost: $20 per child (please contact bfleser@saintbenedictparish for any assistance)

*Please fill out a registration form for each one of your children

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Student's Last Name *
Student's First Name *
Sex *
Student's Date of Birth *
Grade (Rising Grade of Fall 2022) *
Mom's Name (First and Last) *
Mom's Email *
Mom's Phone Number *
Dad's Name (First and Last) *
Dad's Email *
Dad's Phone Number *
Emergency Contact's First and Last Name  (To be used if we can't reach parents). *
Emergency Contact's Phone Numbers *
Dietary Restrictions (allergies) *
Is the participant allergic to anything? List any details of allergies below (this may include food allergies, allergies to medication or chemicals, allergies to any substances) *
Is the participant currently taking or has taken any prescription medication in the last 6 months? Please list medications, reasons for medications, and daily dosage. Please indicate if the medication is currently being administered. *
Does the participant have any emotional, physical or sensory conditions?   List any emotional conditions that may impede participation in the event.  This may include counseling, treatment for emotional conditions (i.e. depression, eating disorders), and/or family situations that may have a significant impact on the participant.  List any physical and/or sensory conditions of which we should be aware or of which need special accommodations (e.g. hearing loss, visual impairment, mobility).   *
Are there any other special notes we need to be aware of (Certain days the children can't attend or other adults who will be picking them up, etc.) *
Pictures of your child participating in activities related to the parish or diocesan events may be posted through St. Benedict Catholic Church and/or Diocese of Richmond publications or websites.  Names of participants will not be used without expressed permission from the parent or guardian.  If you do not want your child’s picture to be used for publications please email the Director of Evangelization of Catechesis of Saint Benedict (  Please note, if you decline to have their picture used we will have to remove them from photographs with their group. Please click the box indicating you understand. *
As parent and/or legal guardian I remain legally responsible for any personal actions taken by the above named minor.  I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to  hold harmless and defend St. Benedict Catholic Church and School the Catholic Diocese of Richmond, its employees and agents, chaperons, or representatives associated with this 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 Diocese, its employees and agents and chaperons, or representatives 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 Diocese.  I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.  In the event of any emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment.  I wish to be advised prior to any further treatment by the hospital or doctor.  In the event of an emergency, if you are unable to reach me at the above numbers I give permission for the noted emergency contact to be notified.  I will not hold St. Benedict Catholic Church and School and the Diocese of Richmond responsible for authorizing any medical treatment beyond necessary transportation to the hospital.                                Please check the box below. *
Parent Signature *
If registering more children, please select the first box below.  If registering multiple children and this is your last registrant, please follow these directions for payment: 1). Click on the link  2). Click on 'One-Time Payment'  3). In the drop box, select 'Religious Education Fees  4). In the 'Amount' box, type the number of the appropriate amount for your total number of registrants (ex. Cost is $20 per registrant so if two registrants, type $40). Please see the image below for directions and then click on the link here to pay: *
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