Saint Columbkille April Vacation Application 2017
The vacation program will be held from Tuesday, April 18 - Friday, April 21 from 8:00 AM to 5:30 PM. Please note there will be no vacation program on Monday, April 17. This program is for students in Pre-K through grade 4.

The fee per child for the program is as follow:
2 Days - $128
3 Days - $190
4 Days - $250

Please note, all payments will be processed through the FACTS Payment Plan on Tuesday, April 18, 2017.

All applications are due by Friday, April 7th.

Email address
Student First Name
Your answer
Student Last Name
Your answer
Grade Level
Days Enrolled
Please check off the days that your child will be attending:
Required
Parent/Guardian Name
Your answer
Home Phone Number
Your answer
Cell Phone Number
Your answer
Work Phone Number
Your answer
Email Address
write NONE if you do not have an email address
Your answer
Parent/ Guardian Name
Your answer
Home Phone Number
Your answer
Cell Phone Number
Your answer
Work Phone Number
Your answer
Email Address
Your answer
Emergency Contact Name
Your answer
Relationship To Student
Your answer
Cell Phone Number
Your answer
Emergency Contact Name
Your answer
Relationship To Student
Your answer
Cell Phone Number
Your answer
Child's Allergies
Your answer
Chronic Health Conditions
Your answer
Child's Physician's Name
Your answer
Physician's Address
Your answer
Physician's Phone Number
Your answer
Health Insurance Plan
Your answer
Policy Number
Your answer
I authorize the staff in the St. Columbkille Vacation Program who are trained in the basics of first aid to administer first aid and/or CPR to my child when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. I hereby authorize the program to transport my child to the nearest medical facility and to secure medical treatment when I cannot be reached or when delay would be dangerous to my child’s health.
I give permission for my child to take part in any and all of the activities planned by the staff of the Saint Columbkille Vacation Program. It is agreed that no liability is assumed by the school, the parish, or school program staff for injuries to persons or damage to property while on these trips. In case of emergency, I give permission for my child to be treated by a physician.
I give permission to the Saint Columbkille Vacation Program to photograph or videotape my child for use in its publications or other public relations materials (television, newspapers, brochures, posters, websites, etc.) to promote its services and program.
Should the bill be posted on the parent's payment plan or is there another responsible party that should be billed?
List the name of the OTHER responsible party (must have an active FACTS payment plan for 16-17) that needs to be billed.
A copy of your responses will be emailed to the address you provided.
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