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Participant 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.
Address 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.
Date of Birth (xx/xx/xxxx) REQUIRED Please fill out this field. Please enter a date.
School REQUIRED Please fill out this field. Please enter valid data.
Grade REQUIRED Please fill out this field.
Parent 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.
Parent Email REQUIRED Please fill out this field. Please enter an email address.
Parent Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Alt. Phone Number Maximum 20 characters Please enter a phone number.
Consent and Liability Waiver
I grant permission for my child to participate in Peace Makers.
I Grant Permission Please select this field.
In consideration of my child's participation in this event, I agree on behalf of myself, my child named herein, and our heirs, successors, and assigns to indemnify, hold harmless, and defend the Archdiocese of Galveston-Houston, the sponsoring parish, its pastor, youth ministry leader, principal, other agents, employees or other representatives associated with the event from any and all inuries, losses or claims arising out of my child's participation in this event.

In checking the box below, I certify that all information contained herein is true and accurate to the best of my knowledge.
I Agree Liability Waiver Please select this field.
Youth Participant

In checking the box below I agree to abide by any/all policies and rules established for this event. Should I not be able to maintain the guidelines and expectations of the adults and my peers, I understand that there will be consequences for my actions, including being removed from the activity and being sent home at my parent's expense
I Agree - Youth Participant Please select this field.
Video/Photography Consent

As parent/guardian, I understand that promotional pictures and videos (individual and group) will be taken during this event. I give permission for my son's/daughter/s picture to be used for promotional materials (newsletter, web page, calendars, power point, video, etc.) in highlighting the event
Video/Photography Consent - choose one REQUIRED I grant permission video/photography I do NOT grant permission video/photography Please fill out this field.
Medical Matters
I hereby warrant to the best of my knowledge, my child is in good healthy, and I assume all responsibility for the health of my child. Of the following statements pertaining to medical matters, sign only those in accordance with your wishes:

Emergency Medical Treatment
In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor and I understand that all financial obligations are my responsibility.
In the event of an emergency and you are unable to reach me, contact:
Name and Relationship: 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.
Family Doctor: 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.
Medications
My child will bring all such medications, well labeled, that are necessary. Names of medications and concise diretions for seeing that the child takes such medications, including dosage and frequency are as follows:
Medications, Dosage, and Instructions:
Please Select One of the Following:
I hereby grant permission for nonprescription medication (such as Tylenol, throat lozenges, cough syrup) to be administered to my child, if deemed advisable. I understand that Aspirin will not be given to my son/daughter. I grant permission to nonprescription medication
I hereby do not grant permission for medication of any type, whether prescription or nonprescription may be administered to my child unless the situation is life-threatening and emergency treatment is required I do NOT grant permission to nonprescription medication
Medical Conditions Information (Archdiocesan personnel will take reasonable care to see that the following information will be held in confidence)

My son/daughter has:
Has had an episode of the following or has been diagnosed: REQUIRED Please fill out this field.
Allergic Reactions to the Following (foods, dyes, latex, etc.) Please enter valid data.
Dietary Restrictions: Please enter valid data.
Has had a medical surgery within the last six months? REQUIRED Yes No Please fill out this field.
If yes to the above, is still under a doctor's care? Yes No
Has a medically prescribed diet? Yes No
The following physical limitations: Please enter valid data.
Immunizations current and up to date? REQUIRED yes no Please fill out this field.
Date of last Tetanus/Diphtheria immunization: Please enter valid data.
You should also be aware of these special medical conditions of my child (e.g. depression, anxiety, etc.):
Insurance Information
Does your child have medical insurance at this time? REQUIRED Yes No Please fill out this field.
Insurance Carrier Please enter valid data.
Name of Insured Please enter valid data.
Policy Number Please enter valid data.
Father's Name Please enter valid data.
Phone Number Maximum 20 characters Please enter a phone number.
Phone Number Maximum 20 characters Please enter a phone number.
Mother's Name Please enter valid data.
In the event it comes to the attention of the chaperones associated with the activity that my child becomes ill with repeated symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called immediately. If this will be a long distance call, I want to be called collect (with phone charges reversed to myself.) I fully understand the foregoing statements and sign this Parental/Guadian Medical Consent Waiver knowingly, freely, and willingly.
I Agree Please select this field.
Date REQUIRED Please fill out this field. Please enter a date.
To proceed to the payment, you have the choice to either pay an initial deposit of your choosing (an amount must be paid for registration) or you may pay the full amount now.

The Full amount for complete registration is $360
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Peacemakers Registration

St. Bernadette Catholic Church
Archdiocese of Galveston-Houston

Office Hours

Register Here!

St. Bernadette Catholic Church Archdiocese of Galveston-Houston

Office Hours

St. Bernadette Catholic Church
Archdiocese of Galveston-Houston