Summer Stretch Participant & Tenor Registration

Date Received: _____________ Check # _____________________
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MEEERRR SSTTTRRREEETTTCCCHHH 22001155 SUMMER STRETCH 2015
PARTICIPANT & TENOR R EGISTRATION FORM
(Participant = means entering into the 7th, 8th, & 9th grades this Fall)
(Tenors = means students entering the 10th grade this Fall)
Registration Form acceptance begins immediately and ends on May 15th
*Please Print All Information Legibly with special attention to the email address *
All below information (front & back) must be completed.
A non-refundable $135.00 fee – must be submitted with form.
(Confidential financial assistance can be arranged by contacting me).
Participant’s name: _______________________________________________________________________________________
(name preferred for a nametag)
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Grade ENTERING in the Fall of 2015: Grade: _______ School: _________________________________
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Age: _____ Gender: _____ Birth Date: ____________ St Ambrose Parishioner: Yes ___ No ___
T-Shirt Size: (adult sizes): SM ____ M ____ LG ____ XL ____
2XL ___ = an additional $2.00
Please PRINT CLEARLY
Student E-Mail: ___________________________________________________________________________________________
(If different from parent)
Student Cell # _______________________________________
Uses Texting? Yes __ No __
Parent E-Mail: ____________________________________________________________________________________________
This is extremely helpful for ongoing communication: please PRINT CLEARLY 
Both Parent First & Last Names:_______________________________________________________________________
Name of Parent most likely to be Driving / Chaperoning: ________________________________________________
Street Address: ___________________________________________________________________________________
City:_____________________________________________ Zip Code:_____________________________
Home # ______________________________________ Work # _____________________________________________
Cell # (MOM) _______________________________________________________ Uses Texting? Yes __ No __
Cell # (DAD)________________________________________________________ Uses Texting? Yes __ No __
Patti Watkins, Director of Faith Formation / [email protected]
Saint Ambrose of Woodbury Catholic Church
4125 Woodbury Drive
Woodbury, MN 55129
Did you remember to pick a T-SHIRT SIZE??
R EGISTRATION FORM Continued…
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MEEERRR SSTTTRRREEETTTCCCHHH 22001155 SUMMER STRETCH 2015
On Wednesdays: June, 24, July, 1, 8, 22, & 29, 2015: 8:00am - 4:30pm
Valley Fair is on Wednesday Aug 05,2015 8:00am to 7:00pm
8:00 am Mass at Saint Ambrose
Parent Car pools leave Saint Ambrose following Mass to go to service sites
Prayer and Lunch at Saint Ambrose – 11:30 a.m.
School bus transportation to afternoon activities – 12:30 p.m.
4:30pm pickups at Saint Ambrose
I, ________________________________________________, grant permission for ____________________________________________
(Parent / Guardian Name)
(Child’s name)
to participate in the above named activity and I warrant that my child is in good health. In consideration of my child’s
participation, I agree to indemnify Saint Ambrose of Woodbury parish and the Archdiocese of St. Paul and Minneapolis from
any claim or law suits brought against Saint Ambrose of Woodbury and the Archdiocese of St. Paul and Minneapolis by
myself, child or others, that arises out of any behavior by my child at the event/activity described above. I also agree to pay
reasonable attorney’s fees or expenses incurred by Saint Ambrose Woodbury Parish and the Archdiocese in defense of such
a claim/lawsuit. EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I give permission to transport my
child to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by a doctor or hospital.
In the event of an emergency, if you are unable to reach me at the above numbers contact:
Emergency Contact: ________________________________________________________________________________
Name (other than parent)
Phone number: ____________________________________________________________________________________
Family Health Plan Group Number: _________________________________________________________________________
Family Doctor:_________________________________________________ Phone:__________________________________
Medication my child is presently taking: ______________________________________________________________________
Allergies: ________________________________________________ Does child carry an Epinephrine Pen (Epi-pen): Yes ___
Allergies to drugs: _______________________________________________________________________________________
FOOD Allergies: ________________________________________________________________________________________
Anything you would like us to be aware of with regards to your child?: ______________________________________________
ATTENTION PARENTS; In acceptance and agreement, please INITIAL EACH below:
► I am aware that I am required to attend ONE (1) of the (4) four scheduled Parent meetings. If I fail to
attend one (1) of the (4) four Parent meetings I understand and agree that my child will not be able to
participate in this year’s Summer Stretch 2015 Program. ________
Parent meeting dates & times to choose from:
Tue 05/12: 7PM-9PM; Thurs 05/14: 10AM-12PM; or Thurs 05/21: either 10AM-12PM or 7PM-9PM
► I understand and agree that all Parents of Participants & Tenors (entering the 7th, 8th,9th &10th grades this
Fall) are Required to Drive at least two (2) times during the morning portion (8:15am – 12:00pm) of our
Summer Stretch Program (Childcare IS provided for our drivers). _______
► I agree, if I am able, to participate as a parent chaperone for lunch-time duties (11:30am-12:30pm) -and
or- for the afternoon (12pm-4:30pm), Recreational Activities on any Wednesday of Summer Stretch 2015
that I will volunteer (this does not, however, take the place of driving requirements). __________
► I understand that all parent / adult chaperones & drivers must have on file with us:
1) Background check 2) Drivers background check 3) Signed Code of Conduct and 4) Completion of a Virtus
training session. And these are all required prior to the start of Summer Stretch Program 2015. ___________
► All information above is complete along with my $135.00 non-refundable fee (checks can be made out to
St. Ambrose of Woodbury Church). ___________
As parent / guardian, I understand and agree to all above considerations and conditions.
Parent Signature: _____________________________________________________________
Date:_______________