Quo Vadis Days

Diocese of Spokane
Registration
July 6-9, 2010

It is very important that you fill out this form entirely,
esp. the *REQUIRED FIELDS!

**Under "YOUR EMAIL", be sure to enter a good email address,
as this is where a confirmation email will be sent!

*Full Name:
**YOUR EMAIL :
Email Subject:
*Street Address:
*City:
*State:
*Zip Code :
*Phone Number:
*Your Parish:
*City of Parish:
Pastor :
School:
Grade Entering:
*Age:
*Birthdate:
*T-Shirt Size:
*Parent/Guardian's Day Phone:
Parent/Guardian Evening Phone:
Parent E-mail:

Health History
Allergies (food, drugs, insects, etc.): Medications (name, dosage, reason): Other information (injuries, special needs, etc.)
Insurance:
Group or ID#
Is your son in general good health and able to participate in all normal youth activites? Yes No Please explain limitations:
In Case of Emergency, Contact:
*Name:
*Address:
*City, State, Zip:
*Phone:
Family Physician:
Address:
City, State, Zip:
Phone:

Comments:

Please be patient! Sometimes this takes several seconds.

You need only to press "Submit to Deacon Lewis" once.

If you are not sure it went through, check the email account you entered at the top of this page (2nd line).

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