2017 V.B.S. REGISTRATIONS DUE BY: JUNE 6th, AT 3 P.M.
REGISTRATION MUST INCLUDE BOTH PARTS TO BE COMPLETE:
† PART ONE: On-line registration at www.churchofsaintmary.com
† PART TWO: This PDF submitted. Follow these 4 steps to complete the PDF part of enrollment:
1. First: please make sure your computer has the free updated Adobe Version DC,
downloaded from Google, before beginning this PDF.
2. Second: download this PDF enrollment and save to your local computer with a name.
3. Third: Open the saved PDF file and begin completing. Your computer should ask you to verify
an electronic signature. After verifying signature, finish PDF and save to your computer again.
4. Fourth: email your completed PART 2 PDF to: [email protected]
Youth Ministry
Vacation Bible School June 12 – 16, 2017
Christine Hassink, V.B.S. Head Director: [email protected]
Valerie Howard, Director of Children’s Ministry PK3 – 5th: [email protected]
Blake Lawson, Director of Youth Ministry 6th – 12th: [email protected]
Phone: 918.749.2561
Parent and teen volunteers are essential for V.B.S. success. Please assist as much as you are able.
Children may come as early as 8:45 a.m. Please check children in with teacher or aid upon arrival.
PRE-SCHOOL (PK3 – Kindergarten): 9 to 11:50 a.m., each day. Home base is in the Pre-School
Center. We start the day in your child’s assigned Pre-School room, then travel to different activity
centers during the morning. Centers include: lesson with activity, crafts, games, music and snacks.
Pre-School children will be dismissed at 11:50 a.m. from their homeroom.
PRIMARY (Grades 1 – 3): 9 a.m. to 12 noon, each day. Home base is the gym. We will open and
close the day with songs and prayer in the gym, and travel to different activity centers during the
morning. Centers include: lesson with activity, crafts, games, music and snacks. Children will be
dismissed from the gym at 12 o’clock noon.
INTERMEDIATE (Grades 4 – 5): 9 a.m. to 12 noon, each day. Home base is Beckerle Hall. The focus
will be the Acts of Mercy. We will have a car wash during the week to earn money for a donation to
the poor. Children will be dismissed from Beckerle Hall at 12 o’clock noon.
MIDDLE SCHOOL (Grades 6 – 8): 9 a.m. to 12:30 p.m., each day. Home base is The Loft. Daily
service projects include travel in town. Parent and child must complete the middle-school release
form.
V.B.S. will meet Friday for Mass at 9 a.m. in the main church, families are invited. Pre-School and
Kindergarten will not attend Mass unless a parent is present and takes them. Families are invited to
the hot dog picnic lunch and closing ceremonies beginning at 11:50 a.m. on Friday.
Child’s Name
(Last, First, Middle)
Gender
M/F
Age
as of
Sept.
1
Birth
Date
Grade School
as of Name
Sept. 1
Date Sacraments Received
Bapt.
Recon.
Euch.
Conf.
Parent/Guardian Names: Mother’s First,Last:_____________________________Father’s First,Last:______________________
Child’s Address__________________________________________________City_________________________Zip____________
E-Mail Address (Print clearly) _____________________________________________________________________________________
Home phone ____________________ Mother’s cell phone ___________________ Father’s cell phone_____________________
Guardian Name and cell phone________________________________________________________________________________
Child resides with:
☐Both Parents
☐Guardian
☐Mother
☐Father
☐Other__________
CHURCH OF SAINT MARY MEDICAL RELEASE FORM for All Children’s
names in the family:
1.___________________________________
2.___________________________________
3.___________________________________
4.___________________________________
5.___________________________________
6.___________________________________
If a medical emergency occurs and I cannot be reached, and/or my child(ren) need(s) immediate care, I hereby
authorize the Faith Formation staff of the Church of Saint Mary to use their best judgment in taking my child(ren)
to a hospital and/or contacting a physician or dentist. I further agree to be responsible for any charges incurred in
relation to obtaining such medical and/or dental care.
This consent will remain effective from June 1, 2017 through August 31, 2018. I understand that every precaution
will be taken to ensure my daughter/son/ward's safety. Should an accident occur, I will not hold the Church of
Saint Mary, Tulsa OK or the Diocese of Tulsa or its paid or volunteer staff responsible.
Signature Parent/Guardian_______________________________________Date __________________/2017
PHONE NUMBER
1.
2.
3.
EMERGENCY PHONE NUMBERS
NAME/RELATIONSHIP
MUST RETURN PAGES 2, 3, 4 (if needed), 5 and 6 (middle school students) FOR
COMPLETE ENROLLMENT TO: [email protected]
page 2 – Everyone must complete and return
CHURCH OF SAINT MARY MEDICAL INFORMATION FORM
Valid June 1, 2017 – August 31, 2018
Complete one form per family
Parent/Guardian:__________________________________________________________Primary Phone: _____________________
(Last Name)
(First Name)
Address: ___________________________________________________________City:________________________Zip:_________
Other Emergency Contact: __________________________________________________Phone:_____________________________
Insurance/Physician Information (Required for all children - Use separate sections for differing children’s information)
Child(ren)’s Name(s): _________________________________________________________________________________________
Physician's Name __________________________________________________Phone:______________
Address: _____________________________________________City:_____________________State:_____Zip:___________
Insurance Carrier: _________________________________________________Policy Number: ________________________
Child’s Name: _________________________________________________________________________________________
Physician's Name: ________________________________________________________Phone:________________________
Address: _____________________________________________City:_____________________State:_____Zip:___________
Insurance Carrier: _________________________________________________Policy Number: ________________________
Child’s Name: _________________________________________________________________________________________
Physician's Name: ________________________________________________________Phone:________________________
Address: _____________________________________________City:_____________________State:_____Zip:___________
Insurance Carrier: _________________________________________________Policy Number: ________________________
Permission for prescribed medication: If any child(ren) require(s) medication please complete the following:
Child One: List any medications being taken at this time.
Child’s Name: _____________________________________________________________________________________________
Name of Medication: __________________________________________ Form: tablet/capsule/liquid/inhaler/injection/nebulizer
Reason for Medication: ___________________________________________________________________________________
Instructions (schedule and dose to be given at parish program):___________________________________________________
Start date: ___________________________End date: __________________________Other:____________________________
Restrictions and/or important side effects: _____________________________________________________________________
Special Storage requirements: ______________________________________ Child may carry medication: No ____Yes____
Child is both capable and responsible for self-administering medication: No___ Yes-Unsupervised___ Yes-Supervised____
I give permission for (name of child) ______________________________________ to receive the medication as indicated above.
Signature of Parent/Guardian: _________________________________________Relationship:_____________
Allergies/special needs:
List any allergies (food, latex, etc.) __________________________________________________________________________________
List any medical conditions/pertinent health information we should be aware of (ADHD, vision or hearing, etc.)_____________________
______________________________________________________________________________________________________________
Child Two: List any medications being taken at this time.
Child’s Name: _____________________________________________________________________________________________
Name of Medication: __________________________________________ Form: tablet/capsule/liquid/inhaler/injection/nebulizer
Reason for Medication: ___________________________________________________________________________________
Instructions (schedule and dose to be given at parish program):___________________________________________________
Start date: ___________________________End date: __________________________Other:____________________________
Restrictions and/or important side effects: _____________________________________________________________________
Special Storage requirements: ______________________________________ Child may carry medication: No ____Yes____
Child is both capable and responsible for self-administering medication: No___ Yes-Unsupervised___ Yes-Supervised____
I give permission for (name of child) ______________________________________ to receive the medication as indicated above.
Signature of Parent/Guardian: _________________________________________Relationship:_____________
Allergies/special needs:
List any allergies (food, latex, etc.) __________________________________________________________________________________
List any medical conditions/pertinent health information we should be aware of (ADHD, vision or hearing, etc.)_____________________
PHOTO/VIDEO RELEASE
For valuable consideration received, I hereby grant to the Church of Saint Mary, the unrestricted right to use and
publish photographs of me/my child(ren) or in which I or my child(ren) are included, for educational, promotional,
celebratory, and any other purpose the church may need – this includes publishing in church mailings,
advertisements, as well as to the internet.
Please check one box:
☐ Yes, I permit this photo release
OR
☐ No, I deny this photo release
Parent/Guardian Signature ______________________________________Date_______________/2017
Page 3 - Everyone under 18 yrs. old must complete and return
Permission for prescribed medication: If any child(ren) require(s) medication please complete the following:
Child Three: List any medications being taken at this time.
Child’s Name: _____________________________________________________________________________________________
Name of Medication: __________________________________________ Form: tablet/capsule/liquid/inhaler/injection/nebulizer
Reason for Medication: ___________________________________________________________________________________
Instructions (schedule and dose to be given at parish program):___________________________________________________
Start date: ___________________________End date: __________________________Other:____________________________
Restrictions and/or important side effects: _____________________________________________________________________
Special Storage requirements: ______________________________________ Child may carry medication: No ____Yes____
Child is both capable and responsible for self-administering medication: No___ Yes-Unsupervised___ Yes-Supervised____
I give permission for (name of child) ______________________________________ to receive the medication as indicated above.
Signature of Parent/Guardian: _________________________________________Relationship:_____________
Allergies/special needs:
List any allergies (food, latex, etc.) __________________________________________________________________________________
List any medical conditions/pertinent health information we should be aware of (ADHD, vision or hearing, etc.)_____________________
______________________________________________________________________________________________________________
Child Four: List any medications being taken at this time.
Child’s Name: _____________________________________________________________________________________________
Name of Medication: __________________________________________ Form: tablet/capsule/liquid/inhaler/injection/nebulizer
Reason for Medication: ___________________________________________________________________________________
Instructions (schedule and dose to be given at parish program):___________________________________________________
Start date: ___________________________End date: __________________________Other:____________________________
Restrictions and/or important side effects: _____________________________________________________________________
Special Storage requirements: ______________________________________ Child may carry medication: No ____Yes____
Child is both capable and responsible for self-administering medication: No___ Yes-Unsupervised___ Yes-Supervised____
I give permission for (name of child) ______________________________________ to receive the medication as indicated above.
Signature of Parent/Guardian: _________________________________________Relationship:_____________
Allergies/special needs:
List any allergies (food, latex, etc.) __________________________________________________________________________________
List any medical conditions/pertinent health information we should be aware of (ADHD, vision or hearing, etc.)_____________________
______________________________________________________________________________________________________________
Permission for prescribed medication: If any child(ren) require(s) medication please complete the following:
Child Five: List any medications being taken at this time.
Child’s Name: _____________________________________________________________________________________________
Name of Medication: __________________________________________ Form: tablet/capsule/liquid/inhaler/injection/nebulizer
Reason for Medication: ___________________________________________________________________________________
Instructions (schedule and dose to be given at parish program):___________________________________________________
Start date: ___________________________End date: __________________________Other:____________________________
Restrictions and/or important side effects: _____________________________________________________________________
Special Storage requirements: ______________________________________ Child may carry medication: No ____Yes____
Child is both capable and responsible for self-administering medication: No___ Yes-Unsupervised___ Yes-Supervised____
I give permission for (name of child) ______________________________________ to receive the medication as indicated above.
Signature of Parent/Guardian: _________________________________________Relationship:_____________
Allergies/special needs:
List any allergies (food, latex, etc.) __________________________________________________________________________________
List any medical conditions/pertinent health information we should be aware of (ADHD, vision or hearing, etc.)_____________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
 All participants (Adult and teen volunteers, nursery-age children, PK3 through 5th
grade, and middle school students must complete Part 1 online at
www.churchofsaintmary.com, and also complete this Part 2 PDF and email to:
[email protected] before your enrollment is complete.
 Volunteers 16 and older must be current with their Virtus certification. Contact
V.B.S. Director or Ministry Leader to discuss current Virtus status.
page 4
ACTIVITY
Sa M T W Th F
Pre-School Coordinator
Pre-School Crafts
Pre-School Faith Lesson
Pre-School Class Leader
Grade K-3 Class Leader
Grade K-3 Music Center
-
Grade K-3 Faith Lesson
-
Grade K-3 Crafts
-
Grade K-3 Games
-
ACTIVITY
Sa M T W Th F
Grade 4-5 Leader
Grade 4-5 Helper
Grade 6-8 Helper
Check-in 8:30-9:30 a.m.
Photographer
Friday Lunch
11 a.m.-1:30 p.m.
Friday Clean-up
10:30 a.m. -1:30 p.m.
Decorate Saturday
6 – 8:30 p.m.
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Please mark the activity and days you will volunteer in the white boxes above. We can only have
V.B.S. with your help. Full-time volunteers are absolutely necessary and parents are needed to
volunteer at least one day. Help decorate on Saturday, June 10th, after the 5 p.m. Mass, if not
available during the week.
Volunteer Name 1._____________________________________ Virtus completed? Date_____________
Phone___________________________________Email___________________________________________
Volunteer Name 2. ____________________________________Virtus completed? Date______________
Phone___________________________________Email___________________________________________
Ages 13 – 17 Teen Volunteer Name_________________________________________________________
Teen name
___________________________Parent sign__________________________Date________
The enrollment requirements for the Nursery, Religious Education, Sacramental Preparation,
Vacation Bible School and for Volunteering are listed in the table below. Please make sure to
complete everything needed, and current Virtus certification is required. Virtus Certification
Packets for 16 and older are provided by RE, Youth and V.B.S. Directors. Background checks for 18
yrs. & older needed every 5 years. Required documents are checked in the yellow boxes below.
Online
Registration
Required
Nursery
PK3-5th
6th-8th
V.B.S.


Medical/
Emergency
Contact
Release
Needed
V.B.S.


Middle
School
Release
Needed
V.B.S.
Photo
Release
Needed
V.B.S.


Self-Safety
Release &
Commitment
Signature
Parental
Consent
Signature
Virtus
Online
Needed
Back
Ground
Check
Required

RE- Commit
9th-12th



13-15 yrs.




volunteer
16-17 yrs.





volunteer
18 & older



volunteer
Sacramental



RE- Commit
Preparation
RE =Need for Religious Education/Sacramental Preparation Only
V.B.S. = Vacation Bible School Only
page 5 Every Adult and Teen Volunteer Must Return
REQUIRED RELEASE FOR MIDDLE SCHOOL ONLY – 6th thru 8th grade
OFF-SITE CONSENT AND WAIVER FORM for YOUTH ACTIVITIES
This form is required of all youth for all off-site trips/activities.
Name of Activity: Middle School V.B.S. 2017 (hereinafter referred to as the Activity and more fully described below).
Participant’s Name:
Address:
Birth Date: ___________ Age: _____ Gender: ______
City/State: ______________________ Zip: _____________
Home Telephone: (_____) __________________ Work: (_____) _________________ Cell: (_____)
Participant resides with (check all that applies): Mother 
Father 
Guardian(s)
Custodial Parent/Legal Guardian’s Name:
Address:
City/State: ______________________ Zip: _____________
Home Telephone: (_____) __________________ Work: (_____) _________________ Cell: (_____)
Emergency Contact:
Relationship: ______________________________
Home Telephone: (_____) __________________ Work: (_____) _________________ Cell: (_____)
PARTICIPATION PERMISSION: I, the undersigned, am custodial parent/legal guardian of Participant and request that he/she
be to allowed participate in the Activity to be held at (Various Locations) located in (Tulsa Metro Area) on (Monday, June
12 -Thursday, June 15), including travel time and all events and activities related to said Activity. Transportation is being
provided by (Outside Bus Provider). I understand that in the event Participant fails to conduct herself/himself in a manner
consistent with the policies of (The Church of Saint Mary and the Diocese of Tulsa), she/he may be requested to leave the
Activity and return home at my expense and that additional disciplinary action may result.
CONSENT TO TREATMENT OF PARTICIPANT: I am the custodial parent or legal guardian of Participant. I hereby warrant that
to the best of my knowledge, Participant is in good health and physically able to participate in the Activity and I assume all
responsibility for the health and physical condition and ability of Participant to so participate.
In the event of circumstances that indicate that Participant is in need of immediate medical care, I authorize and give
permission for Participant to be transported to a hospital/clinic/medical facility for evaluation and emergency medical or
surgical treatment, including any necessary X-ray examination. I authorize any licensed physician or medical center to treat
Participant. I accept full responsibility for any medical or hospital bills associated with the care of Participant.
LIABILITY WAIVER: In consideration of the arrangement set forth herein, I do on behalf of myself, Participant and our
respective heirs, successors, assigns and next of kin, release, waive, hold harmless, defend and covenant NOT TO SUE or
pursue any legal action against, (Church of Saint Mary), the Bishop of the Diocese of Tulsa, and the Diocese of Tulsa and
each of their respective departments, directors, administrators, teachers, officers, agents, representatives, volunteers and
employees from any and all actions, claims, demands or liabilities, including without limitation, those for personal injuries or
property damage, that I and/or Participant may suffer due to illness or injury suffered by Participant as a result of, or in
connection with, participation in the Activity, including the administration of authorized medications, medical treatment
and any consequences that may arise as the result of said treatment, including without limitation, travel to and from the
Activity, housing, meals and collateral entertainment to the fullest extent permitted by law.
I certify to you that the information contained herein is true and correct to the best of my knowledge and that I fully
understand the terms and legal consequences of my execution of this REGISTRATION CONSENT AND WAIVER FORM FOR
YOUTH ACTIVITIES consisting of one (1) page.
SIGNATURE:
Participant’s Signature (12 years and up):
Date____________/2017
Custodial Parent/Guardian Name (please print):
Custodial Parent/Guardian Signature:
Date___________/2017
Middle School V.B.S. 2017
Then they said to each other,
“ Were not our hearts burning within us while he s pok e to
us on the way and opened the s criptures to us ? ” Luke 24:32
And it happened that while two of Jesus’ disciples were conversing and debating
on the road to Emmaus, Jesus himself drew near and walked with them, but their
eyes were prevented from recognizing him.
As he explained the Scriptures to them and then broke bread, their eyes were
opened and they recognized who it was with them; the Risen Lord!
Jesus’ words to the two disciples set they hearts ablaze and at once they returned
to Jerusalem to share the news of Jesus’ Resurrection from the dead.
These words of Jesus are meant for us today as well.
He des ires to s et our hearts ablaze
jus t as he did to his dis ciples !
With hearts set ablaze we’ll share the Good News of God’s love with our neighbors
during our week of Middle School VBS by serving their needs.
We’ll be serving our brothers and sisters at 4 different locations
in the Tulsa area
Monday, June 12 - Thursday, June 15.