St. Michael the Archangel Parish

pittsburgh, PA
Saint Michael the archangel roman catholic parish
is devoted to the worship of almighty god in prayer, sacred liturgy and the sacraments

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Confirmation Retreat 2024

- Children and Teens

Registration and Permission Slip

Confirmation Retreat 2024
The maximum number of form submissions has been reached. This form is currently not available.
- Child Information:
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Birthdate REQUIRED Please fill out this field. Please enter valid data.
  
  Age REQUIRED Please fill out this field. Please enter valid data.
  
  Sex REQUIRED Please fill out this field.
  
  Address REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  School REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Level REQUIRED Please fill out this field. Please enter valid data.
  
  How do you receive your faith formation classes? REQUIRED Please fill out this field.
  
  If other, please name the church or school where you receive faith formation Please enter valid data.
  
  Student allergies, dietary restrictions or special needs
- Parent Information:
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  Email REQUIRED Please fill out this field. Please enter valid data.
- Secondary Contact Information:
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Please fill out this field. Please enter valid data.
- PERMISSION
  
  I/We the parents or guardians of the above mentioned child, for myself/ourselves and for my/our child, give permission for my/our child to participate in the above mentioned program on the above written dates.
- Parent/Guardian First and Last Name REQUIRED Please fill out this field. Please enter valid data.
- Parent/Guardian Signature: REQUIRED Please fill out this field. Please enter valid data.
- Parent Phone Number REQUIRED Please fill out this field. Please enter valid data.
- Parent Email REQUIRED Please fill out this field. Please enter valid data.
- Insurance Company REQUIRED Please fill out this field. Please enter valid data.
- Policy Number REQUIRED Please fill out this field. Please enter valid data.
- Group Number Please enter valid data.
- Special Instructions (For example: Let us know if pre-authorization is needed for medical illness or emergency) Please enter valid data.
- CONSENT TO TREAT
  I/we the undersigned parent(s)/guardian(s) of the above listed child hereby authorize treatment of my/our child by a licensed medical physician in case of any accident or illness that may so arise, or any hospitalization necessary.
- Parent/Guardian Signature: REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.
- This consent form will remain in effect until Please enter a date.
- Medical Matters: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for health of my child. Of the following statements pertaining to medical matters, sign only those in accordance with your wishes.
- Medication by prescription: My child is taking medication at present. My child will bring all such medication necessary, and such medication will be well labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage is as follows:
- Medication: Please enter valid data.
- Parent/Guardian Signature: Please enter valid data.
- Date Please enter a date.
- Over the counter medications: I hereby grant permission for non-prescription medication (such as Tylenol, throat lozenges, cough syrup, etc.) to be given to my child, if deemed advisable.
- Parent/Guardian Signature: Please enter valid data.
- Date Please enter a date.
- 3. No medication. No medication of any type whether prescription or non-prescription medication may be administered to my child unless the situation is life threatening and emergency treatment is required.
- Parent/Guardian Signature: Please enter valid data.
- Date Please enter a date.
- Any known allergies to food or medications? Please enter valid data.
- Any physical limitations? Please enter valid data.
- Any dietary needs? (For example: Let us know if you are diabetic, vegetarian, etc.) Please enter valid data.
- Is the child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, or fainting? If yes, please explain Please enter valid data.
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Confirmation Retreat 2024

PERMISSION

CONSENT TO TREAT