* Required

Parent/Guardian #1 Information

Please provide the one email in the Family Email slot that you would like all CCF correspondences to go to throughout the year.

Parent/Guardian/ Emergency Contact #2 Information

Home Address

Child #1 Information

Please type NMN if no middle name.​

Please provide a copy of your child's baptismal certificate to the CCF Office.

Child #2 Information

Please type NMN if no middle name.​​

Please provide a copy of your child's baptismal certificate to the CCF Office.

Physician and Medical Insurance Info

Parental Permissions

Parental Permission and Liability Release: As parent/legal guardian of the participant names above, I give my permission for my children listed above to participate fully in Faith Formation activities at Our Lady of Good Counsel and for my contact information to be shared with their catechists between September 1, 2021 and May 31, 2022. I agree to indemnify and hereby release the Most Reverend Michael F. Burbidge Bishop of the Catholic Diocese of Arlington and his successors in office, as well as the Catholic Diocese of Arlington and all Diocesan clergy, employees, volunteers, and participating parishes and schools from any and all liability, claims, demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned of the participant resulting from said participant’s involvement in the above mentioned event (including transportation to and from the event). Furthermore, I on behalf of the participant hereby assume all risk of personal injury, sickness, death, damage, and expenses resulting from said participant’s involvement in the above described event.

Consent for Online Educational Platforms: In the event that CCF needs to move to online learning to continue Faith Formation at home, I hereby give consent for my child(ren) to participate in online educational platforms such as; Zoom (Meeting) and Google Classroom/for Education (including Meet, Hangout, and GSuite) used by the Diocese of Arlington at Our Lady of Good Counsel for the 2021-2022 school year.

  • I will be responsible for setting up my child for the class on a specific platform. My child will be expected to participate fully with their the camera and microphone features on these platforms turned on.
  • I understand online educational meetings may be recorded per diocesan policy.
  • I further understand that there is a potential of third-party interference (hacking), and therefore, I will be monitoring each session. I have spoken to my child about what to do should this occur.
  • Should I choose to opt-out of online educational platforms, I must arrange with my parish faith formation leader to homeschool my child(ren).

Informed Consent to Medical Treatment: I request that in my absence the above-named minor be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor. I assume full responsibility for all costs of such treatment. Further, should it be necessary for the participant to return home due to medical, disciplinary, or other reasons, I do hereby assume responsibility for the participant’s transportation home and any costs related thereto.

Photo, Press, Audio, and Electronic Media Release: I authorize the Catholic Diocese of Arlington, its parishes, its schools and/or the Arlington Catholic Herald to use and publish my child’s photograph, video and/or audio recording along with their name identifying them for educational, news stories, illustration and/or marketing purposes.

I understand and hereby agree to the terms and conditions of the participant’s involvement in the above described event and I freely execute this Acknowledgement with full knowledge of its content.

The electronic signature below is treated by Our Lady of Good Counsel Parish as a physical, handwritten signature on a paper document.

Payment Information