Totus Tuus <div> <div> <br /> </div> </div>

Parents and/or Guardians REQUIRED Please fill out this field. Please enter valid data.

Home Parish REQUIRED Please fill out this field. Please enter valid data.

Home Address 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 an email address.

I would like to volunteer to help with Totus Tuus 2019 - please send me more information!

Volunteer Yes No

I have attended the Diocesean VIRTUS training and my paperwork is on file in the parish office

VIRTUS Yes No

Emergency Contact Name REQUIRED Please fill out this field. Please enter valid data.

Emergency Contact Phone Number REQUIRED Please fill out this field. Please enter valid data.

Family Physician REQUIRED Please fill out this field. Please enter valid data.

Physician Phone Number 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.

# of Participants REQUIRED Please fill out this field.
Participant 1
- Child #1 REQUIRED Please fill out this field. Please enter valid data.
- Grade level 2019-2020 REQUIRED Please fill out this field.
- Allergies, Medications & Dosage, Medical Conditions, Food Restrictions REQUIRED Please fill out this field. Please enter valid data.
Participant 2
- Child #1 REQUIRED Please fill out this field. Please enter valid data.
- Grade level 2019-2020 REQUIRED Please fill out this field.
- Allergies, Medications & Dosage, Medical Conditions, Food Restrictions REQUIRED Please fill out this field. Please enter valid data.
Participant 3
- Child #1 REQUIRED Please fill out this field. Please enter valid data.
- Grade level 2019-2020 REQUIRED Please fill out this field.
- Allergies, Medications & Dosage, Medical Conditions, Food Restrictions REQUIRED Please fill out this field. Please enter valid data.
Participant 4
- Child #1 REQUIRED Please fill out this field. Please enter valid data.
- Grade level 2019-2020 REQUIRED Please fill out this field.
- Allergies, Medications & Dosage, Medical Conditions, Food Restrictions REQUIRED Please fill out this field. Please enter valid data.
Participant 5
- Child #1 REQUIRED Please fill out this field. Please enter valid data.
- Grade level 2019-2020 REQUIRED Please fill out this field.
- Allergies, Medications & Dosage, Medical Conditions, Food Restrictions REQUIRED Please fill out this field. Please enter valid data.
Participant 6
- Child #1 REQUIRED Please fill out this field. Please enter valid data.
- Grade level 2019-2020 REQUIRED Please fill out this field.
- Allergies, Medications & Dosage, Medical Conditions, Food Restrictions REQUIRED Please fill out this field. Please enter valid data.
Participant 7
- Child #1 REQUIRED Please fill out this field. Please enter valid data.
- Grade level 2019-2020 REQUIRED Please fill out this field.
- Allergies, Medications & Dosage, Medical Conditions, Food Restrictions REQUIRED Please fill out this field. Please enter valid data.
Participant 8
- Child #1 REQUIRED Please fill out this field. Please enter valid data.
- Grade level 2019-2020 REQUIRED Please fill out this field.
- Allergies, Medications & Dosage, Medical Conditions, Food Restrictions REQUIRED Please fill out this field. Please enter valid data.

Medical Authorization:
I understand that the Catholic Diocese of Wichita, the Oﬃce of Faith Formation, Saint Catherine of Siena and Totus Tuus assume no responsibility for accidents which may occur in associaton with Diocesan events and activities. I agree to use my/our personal insurance to cover any such incidents. I understand that, in the event medical intervention is needed, every attempt will be made to contact the persons listed above. In the event those individuals cannot be reached, I hereby give permission to the physician or any other qualiﬁed medical staﬀ selected by the event leader to hospitalize, secure medical treatment, and/or order injection, anesthesia, or surgery for parcipant as deemed necessary.

Medical Release Yes No

Permission for Other Medical Measures:
In the event it comes to the attention of the Diocesan and/or parish chaperones that my child complains of illness, I grant permission for non-prescripon medication (such as Tylenol, lozenges, etc.) to be given to participant.

Other Medical Measures Yes No

Release of Liability for Youth and Adults:
I understand all reasonable safety precautions will be taken at all measures by the Catholic Diocese of Wichita, the Oﬃce of Faith Formation, Saint Catherine of Siena and Totus Tuus and its employees and agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree to indemnify and hold harmless the Catholic Diocese of Wichita, the Oﬃce of Faith Formation, Saint Catherine of Siena and Totus Tuus, its leaders, employees and volunteer staﬀ from any and all claims arising from or in connection with this event.

Liability Release Yes No

Photo Release:
I hereby authorize the Catholic Diocese of Wichita, the Oﬃce of Faith Formation, Saint Catherine of Siena and Totus Tuus and its agents to utilize photographic and/or video images of me or my child by the Catholic Diocese of Wichita. In giving my consent, I hereby indemnify and hold harmless the Catholic Diocese of Wichita, the Oﬃce of Faith Formation, Saint Catherine of Siena and Totus Tuus and its agents from any and all responsibility of liability. I understand that I will receive no compensation should any photograph and/or video of me or my child be used. Please note that no names will be printed with any photos.

Photo Release Yes No

Code of Behavior for Youth and Adults:
I agree to abide by and/or instruct my child to abide by all rules and regulations as outlined by the aforementioned chaperones/ representaves. I agree that if I/Parcipant fail(s) to abide in any way by the rules, that I/Parcipant can be dismissed from the event and sent home immediately at my/Parcipant’s expense with no right of reimbursement or refund for any amount in connection therewith from the Catholic Diocese of Wichita or its chaperones/representatives.

Code of Behavior Yes No

Parental Consent - Clicking this box acts as your electronic signature

Parental Consent Yes

Saint Catherine of Siena

Wichita, Kansas

Totus Tuus

highlights from totus tuus