Child Registration

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

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

Date REQUIRED Please fill out this field. Please enter a date.

Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

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

Text? Yes No

Home Phone Number Please enter a phone number.

Work Phone Number Please enter a phone number.

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

Individuals who may pick up my children (other than parents): REQUIRED Please fill out this field.

Children participating (Please include name, grade, and tee-shirt size): REQUIRED Please fill out this field.

Health Information:

Do any children have allergies? Yes No

If yes, which child and what allergy? Please enter valid data.

Do children have any disabilities? Yes No

If so, which child and what disability? Please enter valid data.

In an EMERGENCY, if parents cannot be reached, call: REQUIRED

Please state their name, number, and relation to child.

Please fill out this field.

Legal Information: Please check the appropriate box. Describe/ send in documentation if necessary.

Are the children's parents divorced? Yes No

Child has IEP? Yes No

Custody Issues, transportation permissions? Yes No

Court Orders restricting contact with child? Yes No

Issues impacting participation? Yes No

When you submit you will receive a confirmation email.

Thank you! We look forward to seeing you and your children at our Vacation Bible Camp this summer!

God bless!

St. Dominic Parish

Youngstown, Ohio

Child Registration

Printable Registration

Online Registration