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Faith Family Summer Camp

- Ministries
  - Religious Education
  - Faith Family Summer Camp

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- Family last name REQUIRED Please fill out this field. Please enter valid data.
- Address REQUIRED Please fill out this field. Please enter valid data.
- Address 2 Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Father's first name Please enter valid data.
- Father's phone number - home Please enter valid data.
- Father's phone number - cell Please enter valid data.
- Mother's first name Please enter valid data.
- Mother's phone number - home Please enter valid data.
- Mother's phone number - cell Please enter valid data.
- Children 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.
  
  Date of birth REQUIRED Please fill out this field. Please enter valid data.
  
  School attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade in 2024-25 REQUIRED Please fill out this field. Please enter valid data.
  
  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.
  
  Date of birth REQUIRED Please fill out this field. Please enter valid data.
  
  School attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade in 2024-25 REQUIRED Please fill out this field. Please enter valid data.
  
  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.
  
  Date of birth REQUIRED Please fill out this field. Please enter valid data.
  
  School attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade in 2024-25 REQUIRED Please fill out this field. Please enter valid data.
  
  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.
  
  Date of birth REQUIRED Please fill out this field. Please enter valid data.
  
  School attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade in 2024-25 REQUIRED Please fill out this field. Please enter valid data.
  
  Child 5
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of birth REQUIRED Please fill out this field. Please enter valid data.
  
  School attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade in 2024-25 REQUIRED Please fill out this field. Please enter valid data.
  
  Child 6
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of birth REQUIRED Please fill out this field. Please enter valid data.
  
  School attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade in 2024-25 REQUIRED Please fill out this field. Please enter valid data.
  
  Child 7
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of birth REQUIRED Please fill out this field. Please enter valid data.
  
  School attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade in 2024-25 REQUIRED Please fill out this field. Please enter valid data.
  
  Child 8
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of birth REQUIRED Please fill out this field. Please enter valid data.
  
  School attending REQUIRED Please fill out this field. Please enter valid data.
  
  Grade in 2024-25 REQUIRED Please fill out this field. Please enter valid data.
- Does your child(ren) have any special needs, medical conditions or food allergies? If yes, please explain:
- Pick-up & Emergency contacts:
  In the event that I am unable to pick up my child(ren) from camp, the following people have my permission to do so. They also have my permission to be contacted if my child is sick or injured.
- 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.
- 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.
- In the event of an emergency in which I cannot be reached, I authorize the DRE or other Religious Education staff of St Augustine/St. Mary to dial 911, to notify the above listed emergency contacts, and to authorize medical treatment when a physician or EMS deems it necessary for the well-being of my child(ren).
  I Agree Please select this field.
- Photo/media releases
- Child/youth photo/media release
  This authorization release form shall serve as parental/legal guardian permission for the use of my child/children's likeness and/or photographic image of a child/youth where such permission is required. I hereby give permission for my child’s/youth’s name, photographic image (still or video) to appear in Diocesan, Parish, School, or Organization publications and/or websites/social media sites, marketing initiatives. No consideration, monetary or otherwise, shall be paid. I understand that if, for whatever reason, at any point in time, I decide to revoke this agreement and I so notify the Parish, School or Organization in writing, all references to my child’s/youth’s name, likeness and/or photographic image will no longer be used.
  
  I understand that website/social media references and website/social media photographic images will be removed within thirty (30) days of written notification. I understand that the Diocese, Parish, School or Organization is not responsible for access to the information or downloads made by users using websites or social media sites prior to the removal of references (i.e., name, likeness and/or photographic image). I further understand that my child’s/youth’s name, likeness and/or photographic image may continue to be used in any publications already printed or published prior to my revocation of the consent provided herein.
- Please check one REQUIRED I DO grant permission for the use of my child's/youth's name, and I DO grant permission for the use of my child's/youth's photographic image (still or video). I do NOT grant permission for the use of my child’s/youth’s name but I DO grant permission for the use of my child’s/youth’s photographic image (still or video). I do NOT grant permission for the use of either my child’s/youth’s name or photographic image (still or video) to appear in Diocesan, Parish, School or Organization publications and/or websites/social media sites. Please fill out this field.
- Adult photo/media release:
  I, hereby consent to and authorize the use and reproduction by The Roman Catholic Church of St. Augustine in North Bangor (St. Augustine), St. Mary's Church in Brushton (St. Mary's), and the Roman Catholic Diocese of Ogdensburg ("Diocese"), its legal representatives, licensees, successors and assigns, those for whom the Diocese is acting, and those acting with its authority and permission (collectively, the "Authorized Parties"), of any and all photographs, digital images, videotapes or recordings made of me for use by the St. Augustine, St. Mary's, the Diocese, their employees, officers and agents, and the right to copyright and/or use, reuse and/or publish, republish photographic pictures, digital images, videotapes or recordings in conjunction with my name.
  
  I also give permission for the photographs, digital images, videotapes, or recordings to be used in their entirety and/or edited versions as deemed necessary by the St. Augustine, St. Mary's, and the Diocese including the use of images on printed publications or materials, posters, brochures, greeting cards, calendars, electronic publications, or Websites. I represent and warrant that these photographs, digital images, videotapes or recordings belong to me and that there are no third parties holding any proprietary rights in these items, including copyright and trademark.
  
  Furthermore, permission is also given for the photographs, digital images, videotapes, or recordings to be used by St. Augustine, St. Mary's and the Diocese at any time in the future without further clearance from me.
  
  I, hereby release, discharge and agree to save harmless the Roman Catholic Diocese of Ogdensburg and each of the Authorized Parties from any liability, costs or expenses arising by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form whether intentional or otherwise, that may occur or be produced in the taking of the Images or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for infringement of copyright, trademark or any other proprietary rights of third parties, libel, defamation, invasion of privacy, or breach of publicity or other property rights.
  St. Augustine, St. Mary's and the Diocese will not sell these photographs, digital images, videotapes, or recordings to another company and will only use them for the mission of the Church.
  
  If at any point you wish to remove a picture or terminate your release consent form please contact St. Augustine, St. Mary's or the Diocese.
  I have read the foregoing release, authorization and agreement, before signing below, and warrant that I fully understand the contents thereof.
- Consent I agree I do not agree
- Name of adult/parent/legal guardian submitting form:
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Signature REQUIRED Checking this box represents the signature of the adult/parent/guardian submitting the form: Please fill out this field.
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St. Augustine's & St. Mary's

North Bangor & Brushton, NY

Faith Family Summer Camp