Catechesis of the Good Shepherd Registration

CAPTCHA

Student's Name*

First Middle Initial Last

Address*

Street Address Address Line 2 City State ZIP Code

Birthdate*

Age

Gender*

Male
Female

Preschool School Attending*

If not enrolled, indicate None

Parish where your family is registered?*

Baptism Date*

Month and Year required. If not sure of day, enter 01.

Baptism Church*

Church/Parish where Baptized

Baptism Church Location*

Church where Baptized

Mother's Name*

First Last

Cell Phone (Mom)*

If none, enter (000) 000-0000

Father's Name*

First Last

Cell Phone (Dad)*

If none, enter (000) 000-0000

Parent Email*

Onecall Number*

Mom
Dad

Indicate the phone # to be called for the parish Onecall Phone Messaging System

Parent can receive texts?*

Yes
No

Emergency Contact

If parents/guardians are unavailable

Emergency Contact (Non-parent/guardian)*

First Last

If parent is unavailable

Contact Phone Number*

Contact Cell Phone Number

(If different from the other phone number)

Medical Consent granted for Parish to call provider and local hospital, if necessary*

Yes
No

In the event reasonable attempts to contact me are unsuccessful.

To Grant Consent

I hereby give consent for the following medical care provider’s and local hospital to be called:

Physician*

Phone*

Dentist*

Phone*

Preferred Hospital*

Trumbull, 330-841-9011
Akron Children’s Urgent Care, 330-856-9699
St. Joe’s, 330-841-4000

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctors, or, in the event the designated practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any reasonably accessible hospital.

Facts concerning the child’s medical history, including allergies, medications being taken, and any physical impairments to which a doctor should be alerted:

Allergies / Medical Conditions / Education Situations:

Please elaborate

Signature of Parent / Guardian*

Relationship to Student*

Please list your relationship to the student

Refusal To Consent

I do Not give my consent for the emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the Church authorities to take the following action:

Following action for no consent

Signature of Parent / Guardian*

Relationship to Student

Please list your relationship to the student

Email

This field is for validation purposes and should be left unchanged.

Catechesis of the Good Shepherd Registration

CGS Registration Form

Emergency Contact

To Grant Consent

Refusal To Consent