Totus Tuus Registration Form St. Martin Catholic Parish 7148 St. Martins Blvd. Jefferson City, MO 65109 Mass Times Monday: No MassTuesday: 5:30 p.m.; Confessions 5-5:20 p.m.Wednesday: 7:45 a.m.Thursday: 7:45 a.m.Friday: 7:45 a.m.Saturday: 5:30 p.m.; Confessions 4:30-5:15 p.m.Sunday: 7:30 and 10:30 a.m.; Confessions 7-7:15 and 10-10:15 a.m. Contact UsParish Office7148 St. Martins Blvd.Jefferson City, Missouri 65109Office Phone:(573) 893-2923Office Email:parish@stmartinjc.orgOffice HoursMonday: ClosedTuesday-Friday: 8:30 a.m. until 4 p.m.St. Martin Catholic School7206 Bus 50 W.Jefferson City, MO 65109School Phone:(573) 893-3519 Totus Tuus Registration Form To register for Totus Tuus with St. Martin Catholic Parish, please complete the registration form below. Totus Tuus Registration Form Parent/Guardian Name(Required) First Last Children Participating in Totus Tuus(Required)Name of Children (first and last)Allergies, medication, dosage, special needsGrade level for 2023-2024 Add Removeplease click the plus icon to add more childrenAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email(Required) Home Phone(Required)Cell PhoneADDITIONAL EMERGENCY CONTACT INFORMATIONName and phone number of an adult to reach in case of emergency in the event that you cannot be reached at the numbers above. Name(Required) First Last Phone(Required)Name of Family Physician(Required) First Last Family Physician Phone Number(Required)Medical AuthorizationI understand that the Catholic Diocese of Jefferson City and Totus Tuus assume no responsibility for accidents which may occur in association 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/We 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 Participant as deemed necessary. Please verify medical authorization by entering your initials here:(Required) Permission for Other Medical MattersIn 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-prescription medication (such as Tylenol, lozenges, etc.) to be given to Participant. I give consent for the following non-prescription medication as needed: Tylenol Ibprofen Benadryl Cough Drops check all that applyPlease verify consent for other medical matters by entering your initials here:(Required) Release of Liability for Youth and AdultsI understand all reasonable safety precautions will be taken at all times by the Catholic Diocese of Jefferson City 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 and Totus Tuus, its leaders, employees and volunteer staff from any and all claims arising from or in connection with attending this event. Please verify Release of Liability by entering your initials here:(Required) Code of Behavior for Youth and AdultsI agree to abide by and/or instruct my child to abide by all rules and regulations as outlined by the aforementioned chaperones/representatives. I agree that if I/Participant fail(s) to abide in any way by the rules, that I/Participant can be dismissed from the event and sent home immediately at my/Participant’s expense with no right of reimbursement or refund for any amount in connection therewith from the Catholic Diocese of Jefferson City or its chaperones/representatives. Please verify Code of Behavior by entering your initials here:(Required) Photo releaseI hereby authorize the Catholic Diocese of Jefferson City and Totus Tuus and its agents to utilize photographic and/or video images of me or my child by the Catholic Diocese of Jefferson City. In giving my consent, I hereby indemnify and hold harmless the Catholic Diocese of Jefferson City 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.Parent Photo Release Consent(Required) I grant the Diocese of Jefferson City the above rights to use the image of my child I DO NOT grant the Diocese of Jefferson City the above rights to use the image of my child Please verify photo release consent by entering your initials here:(Required) Parent/Guardian Signature(Required) Date(Required) MM slash DD slash YYYY