Queen of the Holy Rosary - Wea School

22705 Metcalf RD
Bucyrus, KS 66013
913.533.2462

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Totus Tuus Registration 2023

- 2023-2024 Payments

Totus Tuus Registration 2023

Please complete the following......
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- Registration Type REQUIRED Please fill out this field.
- Father Information
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Father Address REQUIRED Please fill out this field. 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.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Preferred Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Alternate Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Are you a registered member of the Queen of the Holy Rosary - Wea parish? REQUIRED Yes No Please fill out this field.
  
  If No - what parish do you belong to: Please enter valid data.
- Mother Information
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Mother Address - if different than Father's 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.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Preferred Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Alternate Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Are you a registered member of the Queen of the Holy Rosary - Wea parish? REQUIRED Yes No Please fill out this field.
  
  If No - what parish do you belong to: Please enter valid data.
- Emergency Contact Information
  
  Please provide the name of someone who lives in the area, other than a parent living in the home with the child. In the case of an emergency, my child/children may be released to:
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Child 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.
  
  Alternate Phone Number Maximum 20 characters Please enter a phone number.
- Child(ren) Information
- Number of Children Registering REQUIRED Please fill out this field.
  
  Number of Children Registering 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 a date.
  
  Grade Entering in Fall of 2023 REQUIRED Please fill out this field.
  
  Food Allergies REQUIRED Yes No Please fill out this field.
  
  Any Medical Conditions we should be aware of? REQUIRED Yes No Please fill out this field.
  
  If yes to either above please describe
  
  If Requested - Medication May Be Given Acetaminophen Band-Aid Ibuprofen Neosporin
  
  MEDIA CONSENT
  
  I, we, the parent(s) hereby consent to my child being interviewed, photographed, and/or videotaped by representatives of QHR parish, its agents and independent contractors. Any information or images obtained from those activities may be reproduced by the parish and/or the public media for use in advertising, publicity or educational activities, including, but not limited to, parish publications and/or videos, print and television news and parish websites. I hereby waive any claims I may have and release the parish and its employees from any liability or claims arising out of such activities.
  
  Media Consent for Child REQUIRED Yes No Please fill out this field.
  
  Number of Children Registering 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 a date.
  
  Grade Entering in Fall of 2023 REQUIRED Please fill out this field.
  
  Food Allergies REQUIRED Yes No Please fill out this field.
  
  Any Medical Conditions we should be aware of? REQUIRED Yes No Please fill out this field.
  
  If yes to either above please describe
  
  If Requested - Medication May Be Given Acetaminophen Band-Aid Ibuprofen Neosporin
  
  MEDIA CONSENT
  
  I, we, the parent(s) hereby consent to my child being interviewed, photographed, and/or videotaped by representatives of QHR parish, its agents and independent contractors. Any information or images obtained from those activities may be reproduced by the parish and/or the public media for use in advertising, publicity or educational activities, including, but not limited to, parish publications and/or videos, print and television news and parish websites. I hereby waive any claims I may have and release the parish and its employees from any liability or claims arising out of such activities.
  
  Media Consent for Child REQUIRED Yes No Please fill out this field.
  
  Number of Children Registering 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 a date.
  
  Grade Entering in Fall of 2023 REQUIRED Please fill out this field.
  
  Food Allergies REQUIRED Yes No Please fill out this field.
  
  Any Medical Conditions we should be aware of? REQUIRED Yes No Please fill out this field.
  
  If yes to either above please describe
  
  If Requested - Medication May Be Given Acetaminophen Band-Aid Ibuprofen Neosporin
  
  MEDIA CONSENT
  
  I, we, the parent(s) hereby consent to my child being interviewed, photographed, and/or videotaped by representatives of QHR parish, its agents and independent contractors. Any information or images obtained from those activities may be reproduced by the parish and/or the public media for use in advertising, publicity or educational activities, including, but not limited to, parish publications and/or videos, print and television news and parish websites. I hereby waive any claims I may have and release the parish and its employees from any liability or claims arising out of such activities.
  
  Media Consent for Child REQUIRED Yes No Please fill out this field.
  
  Number of Children Registering 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 a date.
  
  Grade Entering in Fall of 2023 REQUIRED Please fill out this field.
  
  Food Allergies REQUIRED Yes No Please fill out this field.
  
  Any Medical Conditions we should be aware of? REQUIRED Yes No Please fill out this field.
  
  If yes to either above please describe
  
  If Requested - Medication May Be Given Acetaminophen Band-Aid Ibuprofen Neosporin
  
  MEDIA CONSENT
  
  I, we, the parent(s) hereby consent to my child being interviewed, photographed, and/or videotaped by representatives of QHR parish, its agents and independent contractors. Any information or images obtained from those activities may be reproduced by the parish and/or the public media for use in advertising, publicity or educational activities, including, but not limited to, parish publications and/or videos, print and television news and parish websites. I hereby waive any claims I may have and release the parish and its employees from any liability or claims arising out of such activities.
  
  Media Consent for Child REQUIRED Yes No Please fill out this field.
  
  Number of Children Registering 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 a date.
  
  Grade Entering in Fall of 2023 REQUIRED Please fill out this field.
  
  Food Allergies REQUIRED Yes No Please fill out this field.
  
  Any Medical Conditions we should be aware of? REQUIRED Yes No Please fill out this field.
  
  If yes to either above please describe
  
  If Requested - Medication May Be Given Acetaminophen Band-Aid Ibuprofen Neosporin
  
  MEDIA CONSENT
  
  I, we, the parent(s) hereby consent to my child being interviewed, photographed, and/or videotaped by representatives of QHR parish, its agents and independent contractors. Any information or images obtained from those activities may be reproduced by the parish and/or the public media for use in advertising, publicity or educational activities, including, but not limited to, parish publications and/or videos, print and television news and parish websites. I hereby waive any claims I may have and release the parish and its employees from any liability or claims arising out of such activities.
  
  Media Consent for Child REQUIRED Yes No Please fill out this field.
  
  Number of Children Registering 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 a date.
  
  Grade Entering in Fall of 2023 REQUIRED Please fill out this field.
  
  Food Allergies REQUIRED Yes No Please fill out this field.
  
  Any Medical Conditions we should be aware of? REQUIRED Yes No Please fill out this field.
  
  If yes to either above please describe
  
  If Requested - Medication May Be Given Acetaminophen Band-Aid Ibuprofen Neosporin
  
  MEDIA CONSENT
  
  I, we, the parent(s) hereby consent to my child being interviewed, photographed, and/or videotaped by representatives of QHR parish, its agents and independent contractors. Any information or images obtained from those activities may be reproduced by the parish and/or the public media for use in advertising, publicity or educational activities, including, but not limited to, parish publications and/or videos, print and television news and parish websites. I hereby waive any claims I may have and release the parish and its employees from any liability or claims arising out of such activities.
  
  Media Consent for Child REQUIRED Yes No Please fill out this field.
  
  Number of Children Registering 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 a date.
  
  Grade Entering in Fall of 2023 REQUIRED Please fill out this field.
  
  Food Allergies REQUIRED Yes No Please fill out this field.
  
  Any Medical Conditions we should be aware of? REQUIRED Yes No Please fill out this field.
  
  If yes to either above please describe
  
  If Requested - Medication May Be Given Acetaminophen Band-Aid Ibuprofen Neosporin
  
  MEDIA CONSENT
  
  I, we, the parent(s) hereby consent to my child being interviewed, photographed, and/or videotaped by representatives of QHR parish, its agents and independent contractors. Any information or images obtained from those activities may be reproduced by the parish and/or the public media for use in advertising, publicity or educational activities, including, but not limited to, parish publications and/or videos, print and television news and parish websites. I hereby waive any claims I may have and release the parish and its employees from any liability or claims arising out of such activities.
  
  Media Consent for Child REQUIRED Yes No Please fill out this field.
  
  Number of Children Registering 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 a date.
  
  Grade Entering in Fall of 2023 REQUIRED Please fill out this field.
  
  Food Allergies REQUIRED Yes No Please fill out this field.
  
  Any Medical Conditions we should be aware of? REQUIRED Yes No Please fill out this field.
  
  If yes to either above please describe
  
  If Requested - Medication May Be Given Acetaminophen Band-Aid Ibuprofen Neosporin
  
  MEDIA CONSENT
  
  I, we, the parent(s) hereby consent to my child being interviewed, photographed, and/or videotaped by representatives of QHR parish, its agents and independent contractors. Any information or images obtained from those activities may be reproduced by the parish and/or the public media for use in advertising, publicity or educational activities, including, but not limited to, parish publications and/or videos, print and television news and parish websites. I hereby waive any claims I may have and release the parish and its employees from any liability or claims arising out of such activities.
  
  Media Consent for Child REQUIRED Yes No Please fill out this field.
  
  Number of Children Registering 9
  
  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 a date.
  
  Grade Entering in Fall of 2023 REQUIRED Please fill out this field.
  
  Food Allergies REQUIRED Yes No Please fill out this field.
  
  Any Medical Conditions we should be aware of? REQUIRED Yes No Please fill out this field.
  
  If yes to either above please describe
  
  If Requested - Medication May Be Given Acetaminophen Band-Aid Ibuprofen Neosporin
  
  MEDIA CONSENT
  
  I, we, the parent(s) hereby consent to my child being interviewed, photographed, and/or videotaped by representatives of QHR parish, its agents and independent contractors. Any information or images obtained from those activities may be reproduced by the parish and/or the public media for use in advertising, publicity or educational activities, including, but not limited to, parish publications and/or videos, print and television news and parish websites. I hereby waive any claims I may have and release the parish and its employees from any liability or claims arising out of such activities.
  
  Media Consent for Child REQUIRED Yes No Please fill out this field.
  
  Number of Children Registering 10
  
  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 a date.
  
  Grade Entering in Fall of 2023 REQUIRED Please fill out this field.
  
  Food Allergies REQUIRED Yes No Please fill out this field.
  
  Any Medical Conditions we should be aware of? REQUIRED Yes No Please fill out this field.
  
  If yes to either above please describe
  
  If Requested - Medication May Be Given Acetaminophen Band-Aid Ibuprofen Neosporin
  
  MEDIA CONSENT
  
  I, we, the parent(s) hereby consent to my child being interviewed, photographed, and/or videotaped by representatives of QHR parish, its agents and independent contractors. Any information or images obtained from those activities may be reproduced by the parish and/or the public media for use in advertising, publicity or educational activities, including, but not limited to, parish publications and/or videos, print and television news and parish websites. I hereby waive any claims I may have and release the parish and its employees from any liability or claims arising out of such activities.
  
  Media Consent for Child REQUIRED Yes No Please fill out this field.
- Name of Physician REQUIRED Please fill out this field. Please enter valid data.
- Physician Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Name of Dentist REQUIRED Please fill out this field. Please enter valid data.
- Dentist Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Hospital Preference REQUIRED Please fill out this field. Please enter valid data.
- Insurance Company REQUIRED Please fill out this field. Please enter valid data.
- Insurance Policy Number REQUIRED Please fill out this field. Please enter valid data.
- 1.   Parental Permission for Youth under 18 - I, we, the parent(s), request that our child be allowed to participate in the following activity, and do hereby grant permission for the child(ren) named above to participate in Totus Tuus of KCK to be held June 10-17, 2023 at Queen of the Holy Rosary, Wea.
  
  2.   Medical Permission for Youth and Adults - I, we, the parent(s) grant permission in the event I/my child is injured or becomes ill for medical care to be administered to me/my child and to use my/our personal insurance to cover such incidents. After discussion with the emergency contact, I, we, the parent(s) hereby give permission to the physician selected to render medical treatment deemed necessary and appropriate by the physician.
  
  3.   Release of Liability for Youth and Adults - I, we, the parent(s), do hereby release, forever discharge and agree to hold harmless the Office of Evangelization, Office of Children's Catechesis, and the Archdiocese of Kansas City in Kansas, and also Queen of the Holy Rosary Catholic Church, Wea from and against any and all kind of liability, claims, demands, lawsuits, and expenses of any kind arising from personal injury, sickness, death or property damage of any kind whatsoever which may be incurred or suffered by your child.
  I, we, the parent(s) further agree to indemnify and hold harmless the Office of Evangelization, Office of Children's Catechesis, and the Archdiocese of Kansas City in Kansas and also Queen of the Holy Rosary Catholic Church, Wea and their respective members, officers, directors and employees, agents, sponsors and promoters from any and all liability, claim, loss, damage, cost or expense and waive any such claims against persons or organizations arising directly or indirectly from or attributable in any action or omission to act of any such person or organization in connection with the sponsorship, organization, and execution of the event named.
  I Agree Please select this field.
- Convenience Fee Payment Type REQUIRED
  A convenience fee is required and different depending on your payment type. How are you paying for this - Electronic Check or Credit Card?
  Please fill out this field.
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Totus Tuus Registration 2023

MEDIA CONSENT

MEDIA CONSENT

MEDIA CONSENT

MEDIA CONSENT

MEDIA CONSENT

MEDIA CONSENT

MEDIA CONSENT

MEDIA CONSENT

MEDIA CONSENT

MEDIA CONSENT