St. John Vianney
Catholic Church, Fishers, IN

A Pastorate of the Diocese of Lafayette-in-Indiana

Camp Rose

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  Camp Rose Registration Form
  
  Parent 1 (Please put the parent who will be the main contact for Camp Rose communication)
  
  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 Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Parent 2 Please enter valid data.
  
  First Name Please enter valid data.
  
  Last Name Please enter valid data.
  
  Phone Number Maximum 20 characters Please enter a phone number.
  
  Email Please enter an email address.
  
  In case of an emergency every effort will be made to contact you, the parent(s) using the information provided above. Please provide an alternate emergency contact (not already listed) in case we are unable to reach either parent.
  
  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 Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  How many children are you registering? REQUIRED Please fill out this field.
  
  Child 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  What grade will this child be entering? REQUIRED Please fill out this field.
  
  Does this child have an I.E.P? REQUIRED Please fill out this field.
  
  Does this child have any allergies, medical or learning needs you would like for us to be aware of?
  
  What size t-shirt would you like for this child? REQUIRED Please fill out this field.
  
  Child 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  What grade will this child be entering? REQUIRED Please fill out this field.
  
  Does this child have an I.E.P? REQUIRED Please fill out this field.
  
  Does this child have any allergies, medical or learning needs you would like for us to be aware of?
  
  What size t-shirt would you like for this child? REQUIRED Please fill out this field.
  
  Child 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  What grade will this child be entering? REQUIRED Please fill out this field.
  
  Does this child have an I.E.P? REQUIRED Please fill out this field.
  
  Does this child have any allergies, medical or learning needs you would like for us to be aware of?
  
  What size t-shirt would you like for this child? REQUIRED Please fill out this field.
  
  Child 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  What grade will this child be entering? REQUIRED Please fill out this field.
  
  Does this child have an I.E.P? REQUIRED Please fill out this field.
  
  Does this child have any allergies, medical or learning needs you would like for us to be aware of?
  
  What size t-shirt would you like for this child? REQUIRED Please fill out this field.
  
  Liability and Permission:
  We, as parents/guardians of the minor(s) whom we are registering for St. John Vianney's Camp Rose Day Camp, hereby consent and agree to hold harmless St. John Vianney Parish and/or the Roman Catholic Diocese of Lafayette-in-Indiana, Inc., and any and all employees or volunteers thereof, for any accident, injury or occurrence arising out of, or in connection with the aforementioned activity.
  
  I have read and understood the consent to hold harmless St. John Vianney Catholic Church and the Diocese of Lafayette-in-Indiana. REQUIRED Yes, I understand Please fill out this field.
  
  I understand that photos of my child, may be used for parish media such as SJV's Facebook, SJV's Instagram, parish bulletin and wesite, as well as The Catholic Moment. No names will be used in any picture of your child. REQUIRED Yes, I understand Please fill out this field.
  
  In order to ensure a successful Camp Rose for your children, we will need your help. Please indicate which areas you are interested in assisting us with. A sign-up link will be emailed at a later date. REQUIRED Please fill out this field.
  
  Would you like to purchase additional t-shirts at $12 each?
  
  How many additional t-shirts will you be purchasing? REQUIRED Please fill out this field.
  
  Extra T-Shirt 1
  
  What size shirt would you like?
  
  Extra T-Shirt 2
  
  What size shirt would you like?
  
  Extra T-Shirt 3
  
  What size shirt would you like?
  
  Extra T-Shirt 4
  
  What size shirt would you like?
  
  Payment Information:
  
  $100.00 per child
  
  Paying by check or cash?
  Checks can be made payable to St. John Vianney Catholic Church, in the memo line please write "Camp Rose".
  
  Drop off exact cash and check payments at the main office, Monday thru Friday, 9am-3pm. For after hours drop off you may place payment in the secure drop box located at the exterior of Door #2.
  
  Our mailing address is: St. John Vianney Catholic Church, 15176 Blessed Mother Blvd., Fishers, IN 46037
  
  Paying with a credit card?
  Online payment is available thru our parish website. From the home page you can select "Online Giving" and select "Religious Education" to pay with a credit card.
  
  Registration is not complete until payment is received.
  
  Thank you!
  
  Submit
  
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Camp Rose

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ST. JOHN VIANNEY CATHOLIC CHURCH