Church of the Holy Family Catholic Church/Art and Environment Camp Registration/Virginia Beach, VA

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Middle School Registration
- Number of Campers Registering REQUIRED Please fill out this field.
- Middle School Camper 1
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Preferred Name/Nickname Please enter valid data.
  - Date of Birth REQUIRED Please fill out this field. Please enter a date.
  - Gender REQUIRED Please fill out this field.
  - Grade (for the upcoming school year 2023-2024) REQUIRED Please fill out this field.
  - Name of Middle School REQUIRED Please fill out this field. Please enter valid data.
  - My child has special needs, learning accommodations, and/or medical or food allergies: REQUIRED Yes No Please fill out this field.
  - If yes, please describe below so we can better assist your child.
  - Middle School Camp Registration Fee50.0
- Middle School Camper 2
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Preferred Name/Nickname Please enter valid data.
  - Date of Birth REQUIRED Please fill out this field. Please enter a date.
  - Gender REQUIRED Please fill out this field.
  - Grade (for the upcoming school year 2023-2024) REQUIRED Please fill out this field.
  - Name of Middle School REQUIRED Please fill out this field. Please enter valid data.
  - My child has special needs, learning accommodations, and/or medical or food allergies: REQUIRED Yes No Please fill out this field.
  - If yes, please describe below so we can better assist your child.
  - Middle School Camp Registration Fee50.0
- Middle School Camper 3
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Preferred Name/Nickname Please enter valid data.
  - Date of Birth REQUIRED Please fill out this field. Please enter a date.
  - Gender REQUIRED Please fill out this field.
  - Grade (for the upcoming school year 2023-2024) REQUIRED Please fill out this field.
  - Name of Middle School REQUIRED Please fill out this field. Please enter valid data.
  - My child has special needs, learning accommodations, and/or medical or food allergies: REQUIRED Yes No Please fill out this field.
  - If yes, please describe below so we can better assist your child.
  - Middle School Camp Registration Fee50.0
- Middle School Camper 4
  - First Name REQUIRED Please fill out this field. Please enter valid data.
    
    Last Name REQUIRED Please fill out this field. Please enter valid data.
  - Preferred Name/Nickname Please enter valid data.
  - Date of Birth REQUIRED Please fill out this field. Please enter a date.
  - Gender REQUIRED Please fill out this field.
  - Grade (for the upcoming school year 2023-2024) REQUIRED Please fill out this field.
  - Name of Middle School REQUIRED Please fill out this field. Please enter valid data.
  - My child has special needs, learning accommodations, and/or medical or food allergies: REQUIRED Yes No Please fill out this field.
  - If yes, please describe below so we can better assist your child.
  - Middle School Camp Registration Fee50.0
Parent/Guardian Information
Father
First Name Please enter valid data.

Last Name Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Mother
First Name Please enter valid data.

Last Name Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
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.
Email REQUIRED Please fill out this field. Please enter an email address.
Pick Up Information
OTHER THAN PARENTS, individuals authorized to pick up children listed above:
First Name Please enter valid data.

Last Name Please enter valid data.
Phone Number Maximum 20 characters Please enter a phone number.
First Name Please enter valid data.

Last Name Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
List below any individuals NOT AUTHORIZED to pick up:
First/Last Name Please enter valid data.
Medical Release
As parent and/or legal guardian I remain legally responsible for any personal actions taken by the above named minor(s). I agree on behalf of myself, my child(ren) named herein, or our heirs, successors, and assigns, to hold harmless and defend the Catholic Diocese of Richmond, its employees and agents, chaperones, or representatives associated with this event from any claim arising from or in connection with my child(ren) 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 chaperones, 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 Parish and Diocese.

I hereby warrant that to the best of my knowledge, my child(ren) is/are in good health, and I assume all responsibility for the health of my child(ren). 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 the Diocese of Richmond responsible for authorizing any medical treatment beyond necessary transportation to the hospital.
I Agree Please select this field.
Electronic Signature for Medical Release
First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Release for Use of Photos and/or Videos
I give permission for pictures and/or video of my child(ren) named above engaged in activities related to any Parish and Diocesan event to have their pictures posted in the Diocese of Richmond publications or websites. Names of participants will not be used without expressed permission from the parent or guardian. If no box is checked below, the Diocese of Richmond assumes you give permission.
Please select one: REQUIRED Yes, I give permission. No, I do not give my permission. Please fill out this field.
Electronic Signature for Use of Photos/Videos
First Name REQUIRED Please fill out this field. Please enter valid data.

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

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Art and Environment Camp Registration

Middle School Registration

Parent/Guardian Information

Pick Up Information

OTHER THAN PARENTS, individuals authorized to pick up children listed above:

List below any individuals NOT AUTHORIZED to pick up:

Medical Release

Release for Use of Photos and/or Videos