PULSE REGISTRATION

Sunday Evenings
St. Mary School

10/25/26, 11/22/26, 12/20/26, 1/17/27, 2/14/27, 3/7/27, 4/11/27
Grades 6 – 8^th

** Form needs to be completed only once for the PULSE year. **

Step 1 of 3

Parent / Guardian #1 Contact Information

This is the primary contact for your child(ren) for the Catholic Formation Department.

Parent / Guardian #1 Name:

First

Last

Parent / Guardian #1 Email:

Parent / Guardian #1 Phone Number:

Parent / Guardian #1 Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact?

This person is the emergency contact

Parent / Guardian #2 Contact Information

Parent / Guardian #2 Name:

First

Last

Parent / Guardian #2 Email:

Parent / Guardian #2 Phone Number:

Parent / Guardian #2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact?

This person is the emergency contact

General Information

Your Primary Church:

Emergency Medication information

Event Information (IC-Pulse)

Description of Event: Pulse
Date of Event: 10/25/26, 11/22/26, 12/20/26, 1/17/27, 2/14/27, 3/7/27, 4/11/27 (6:00pm – 7:00pm)
Transportation Method: None
Participant cost: Free
Sponsored by: Immaculate Conception Church & St. Patrick Church
Supervised by: Catholic Formation Team members and volunteers

Participant Registration Section

Please fill out the form below for each child that you are registering. To add another child, please click on the “Add Child” button at the bottom of the form for more child forms.

Child Registration

Child's Name:

First

Last

Date of Birth:

Gender:

Grade Level (In Fall):

Special Needs (Medical, Learning Disabilities, Physical Disabilities, etc.):

Do you need to submit a Medication Consent Form for this child?

If you selected “Yes”, you need to submit a Medication Consent Form. Please download the form here, fill out the form digitally and upload the completed form on the next page. Please include your child’s name within the saved form’s filename.

Participation Permission

I consent and give my permission

I give permission for my child to participate in the above named event. My signature below indicates that I understand the risks and hazards associated with this event, including injury, illness and the rare possibility of death. I understand that I may discuss any concerns or questions I have about this event with a representative of the parish or Diocese of Superior prior to giving permission for my child to participate.

In consideration for my child’s participation, I agree to reimburse and indemnify the above named parish and the Diocese of Superior for all reasonable legal and court fees incurred by the parish/diocese in defending a lawsuit that I or my child may bring against the parish/diocese which relates to the above named event if the parish/diocese is found not legally liable by the courts and prevails in the lawsuit. If the parish/diocese is found legally liable for any injuries sustained by my child, this paragraph will not apply. I further agree to reimburse the diocese or any other agency for property damage or any bodily harm to other participants caused by my child.

Child's Primary Physician

First

Last

Physician Phone Number:

Health System & Location

Health Insurance Carrier

Policy Number

Signature

Clear Signature

SATURDAY	5:00 PM
SUNDAY	9:00 AM

TUESDAY	5:00 PM
WEDNESDAY	9:45 AM	8:15 AM Non-School Year
THURSDAY	8:15 AM
FRIDAY	8:15 AM

Registration (CF Pulse)

PULSE REGISTRATION

Parent / Guardian #1 Contact Information

Parent / Guardian #2 Contact Information

General Information

Event Information (IC-Pulse)

Participant Registration Section

Child Registration

Required Forms