C.C.D. Registration – St. Rose Catholic Church

When registering your children for C.C.D., you have the option to either submit the form online or download and print a version of this registration form and return it to the Parish Office. You may place the downloaded and completed registration form in an envelope marked “C.C.D” in the Sunday Collection, you may drop it off at the Rectory, or you may mail the registration and tuition to the Rectory to the Attention of Mrs. Jeannine Frederick.

St. Rose CCD & YM Emergency Medical Authorization

To enable parents/guardians to authorize the provision of emergency treatment for a child who becomes ill or injured while attending the CCD or YM Program at St. Rose Parish. CCD & YM Location: St. Rose School, St. Rose Church, Rosetta Hall, and Parish Grounds.

Child's Name*
Please fill this out separately for each of your children.
Grade
Address
Phone Number
Medical Consent Decision*
- I hereby give my consent for: the administration of any treatment deemed necessary by my preferred physician, preferred dentist or in the event the designated preferred practitioner is not available, by another licensed physician or dentist and the transfer of the child to my preferred hospital or any hospital reasonable accessible This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery are obtained prior to the performance of such surgery. Every effort will be made to contact the Parent/Guardian first. If you consent
- I do not consent to Emergency Medical Authorization for my child.
Preferred Physician
Preferred Dentist
Preferred Hospital
Medical Insurance Coverage
- My son/daughter is covered by hospitalization and medical insurance.
- My son/daughter does not have medical coverage, and I assume the responsibility for the cost of the hospitalization and medical care for my son/daughter.
Medical Insurance Policy Number
Medical Insurance Policy Issued by;
If I can not be reached, please contact: (include name and number)
Additional Medical Information (medications, allergies, illness, etc.)
Electronic Signature of Parent/Guardian*
Today's Date*

Family Information:

Participant Information:

St. Rose CCD & YM Emergency Medical Authorization