Kenrick-Glennon Days Registration Form

Kenrick-Glennon Days Junior Counselor Permission & Liability Waiver

Phone

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

General Information

Junior Counselor's First and Last Name(Required)

Date of Birth(Required)

Street Address(Required)

City, State and Zip Code(Required)

Home Parish(Required)

Grade in School (Fall 2026)(Required)

Parent(s) Name(s)(Required)

Parent(s) Phone(Required)

T-Shirt Size (adult sizes)(Required)

Parent(s) email address(Required)

Emergency Contact Name and Phone(Required)

Health Information

Is this participant in general good health and able to participate in general activities (if not, please explain).(Required)

Name of JC's physician(Required)

Physician's phone number(Required)

Address of physician (street, city, state, zip code)(Required)

Date of last tetanus booster(Required)

Is your son presently taking any medications?(Required)

yes

If yes, please list them and provide directions for frequency and dosage.

Will your son be bringing any over the counter medications with him?(Required)

yes

If so, please list them:

Please list any special dietary needs:

Health Insurance Company(Required)

Health Insurance Policy #(Required)

Name of Primary Health Insurance Holder(Required)

Permissions and Liability

Please check all that apply:(Required)

I hereby certify that the above information is correct and give permission for the release of medical records to an attending physician in case of illness. In case of medical emergency, I understand that every effort will be made to contact parent(s) or guardian(s) of participants. In the event that I cannot be reached, I hereby give permission to the physician selected by the Archdioceses of Kansas City and/or St. Louis to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for my child, as named herein.

I request that my son be allowed to participate in, and be transported to and from, Kenrick-Glennon Days at Kenrick-Glennon Seminary in St. Louis, MO. I hereby release and indemnify the Archdiocese of Kansas City in Kansas and/or and Archdiocese of St. Louis, its staff, and volunteers from any liability arising from claims of any kind or nature whatsoever from my son's participation in this program.

My son may be given over the counter medication (such as Tylenol, Tums, Advil, cough drops).

During the seminary visit, I give my permission to the Archdioceses of Kansas City in Kansas and/or St. Louis to take photographs and video of my child to possibly be used for future promotional items.

Parent's Electronic Signature

Today's Date

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Kenrick-Glennon Days Junior Counselor Permission & Liability Waiver

General Information

Health Information

Permissions and Liability

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