Father's Name *

First Name

Last Name

Father's Cell Phone *

(###)

###

####

Mother's Name *

First Name

Last Name

Mother's Cell Phone *

(###)

###

####

Family Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child lives with *

First Name

Last Name

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

#1 Child's Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

#2 Child's Name

First Name

Last Name

Birth Date

MM

DD

YYYY

#3 Child's Name

First Name

Last Name

Birth Date

MM

DD

YYYY

#4 Child's Name

First Name

Last Name

Birth Date

MM

DD

YYYY

#5 Child's Name

First Name

Last Name

Birth Date

MM

DD

YYYY

Participation Waiver

As a parent/guardian of the child(ren) listed on this form, permission is hereby given for my child(ren) to participate in activities sponsored by St. Pius X. I recognize that engaging in the activities at St. Pius X may expose my child (ren) to the possibility of physical injury and agree to hold St. Pius X Catholic Church harmless, as well as their employees, organizers, and any volunteers assisting in the programs, from liability and claims arising out of my child's participation in programs subsidiaries, and related activities.

I agree

I do not agree

Photograph Waiver

As part of the education programs, pictures are occasionally taken of the students participating in activities and events. Please, indicate below whether St. Pius X may include pictures of your child(ren) in our parish bulletin or on the parish website/social media. WE WILL NOT IDENTIFY YOUR CHILD(REN) BY NAME.

I agree

I do not agree