{"id":5019,"date":"2026-06-23T18:57:05","date_gmt":"2026-06-23T18:57:05","guid":{"rendered":"https:\/\/www.stwilliamchampion.org\/?page_id=5019"},"modified":"2026-06-24T13:32:44","modified_gmt":"2026-06-24T13:32:44","slug":"emergency-medical-form","status":"publish","type":"page","link":"https:\/\/stwilliamchampion.org\/?page_id=5019","title":{"rendered":"Emergency Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5019\" class=\"elementor elementor-5019\">\n\t\t\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-04d22eb elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"43406\" data-id=\"04d22eb\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-af5bc26\" data-eae-slider=\"55046\" data-id=\"af5bc26\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-47f4ec6 elementor-widget elementor-widget-spacer\" data-id=\"47f4ec6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-d457af9 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"28038\" data-id=\"d457af9\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-0705475\" data-eae-slider=\"46020\" data-id=\"0705475\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-cd334d4 elementor-widget elementor-widget-image\" data-id=\"cd334d4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"500\" height=\"500\" src=\"https:\/\/stwilliamchampion.org\/wp-content\/uploads\/2026\/03\/2.png\" class=\"attachment-large size-large wp-image-4839\" alt=\"\" srcset=\"https:\/\/stwilliamchampion.org\/wp-content\/uploads\/2026\/03\/2.png 500w, https:\/\/stwilliamchampion.org\/wp-content\/uploads\/2026\/03\/2-300x300.png 300w, https:\/\/stwilliamchampion.org\/wp-content\/uploads\/2026\/03\/2-150x150.png 150w\" sizes=\"(max-width: 500px) 100vw, 500px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-66 elementor-top-column elementor-element elementor-element-356c2b9\" data-eae-slider=\"24431\" data-id=\"356c2b9\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-bb174f4 elementor-widget elementor-widget-heading\" data-id=\"bb174f4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Trumbull North Catholic Community<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e6bba94 elementor-widget elementor-widget-heading\" data-id=\"e6bba94\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Emergency Medical Authorization Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-56b2134 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"57877\" data-id=\"56b2134\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-81143b6\" data-eae-slider=\"70413\" data-id=\"81143b6\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-a069526 elementor-widget elementor-widget-wpforms\" data-id=\"a069526\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-4599\"><form id=\"wpforms-form-4599\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"4599\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F5019\" data-token=\"b5cf6f48e301f10b2caf52656bc80858\" data-token-time=\"1790004521\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-4599-field_1-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"1\"><h3 id=\"wpforms-4599-field_1\" aria-errormessage=\"wpforms-4599-field_1-error\">Child Information<\/h3><\/div><div id=\"wpforms-4599-field_2-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"2\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-4599-field_2\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][2][first]\" placeholder=\"e.g., Emily \" aria-errormessage=\"wpforms-4599-field_2-error\" required><label for=\"wpforms-4599-field_2\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-4599-field_2-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][2][last]\" placeholder=\"Johnson\" aria-errormessage=\"wpforms-4599-field_2-last-error\" required><label for=\"wpforms-4599-field_2-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-4599-field_48-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_48\">Church at which your child will be attending Faith Formation <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-4599-field_48\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][48]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>--- Select Choice ---<\/option><option value=\"St. Robert\"  class=\"choice-1 depth-1\"  >St. Robert<\/option><option value=\"St. Thomas\"  class=\"choice-2 depth-1\"  >St. Thomas<\/option><option value=\"St. William\"  class=\"choice-3 depth-1\"  >St. William<\/option><option value=\"None of the Above\"  class=\"choice-4 depth-1\"  >None of the Above<\/option><\/select><\/div><div id=\"wpforms-4599-field_3-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"3\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-4599-field_4-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_4\">Date of Birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4599-field_4\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][4][date]\" placeholder=\"MM\/DD\/YY\" aria-errormessage=\"wpforms-4599-field_4-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-4599-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_6\">Grade Level <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4599-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" placeholder=\"e.g., 5th Grade\" aria-errormessage=\"wpforms-4599-field_6-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-4599-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_5\">Gender <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4599-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" placeholder=\"e.g., Female\" aria-errormessage=\"wpforms-4599-field_5-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-4599-field_43-container\" class=\"wpforms-field wpforms-field-address\" data-field-type=\"address\" data-field-id=\"43\"><fieldset><legend class=\"wpforms-field-label\">Home Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-4599-field_43\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][43][address1]\" aria-errormessage=\"wpforms-4599-field_43-error\" required><label for=\"wpforms-4599-field_43\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-4599-field_43-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][43][city]\" aria-errormessage=\"wpforms-4599-field_43-city-error\" required><label for=\"wpforms-4599-field_43-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-4599-field_43-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][43][state]\" aria-errormessage=\"wpforms-4599-field_43-state-error\" required><label for=\"wpforms-4599-field_43-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-4599-field_43-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][43][postal]\" aria-errormessage=\"wpforms-4599-field_43-postal-error\" required><label for=\"wpforms-4599-field_43-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-4599-field_43-country\" class=\"wpforms-field-address-country wpforms-field-required\" name=\"wpforms[fields][43][country]\" aria-errormessage=\"wpforms-4599-field_43-country-error\" required><option class=\"placeholder\" value=\"\" selected disabled>--- Select country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-4599-field_43-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-4599-field_8-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"8\"><h3 id=\"wpforms-4599-field_8\" aria-errormessage=\"wpforms-4599-field_8-error\">Primary Emergency Contact<\/h3><\/div><div id=\"wpforms-4599-field_9-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"9\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-4599-field_10-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_10\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4599-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" placeholder=\"e.g., Laura Johnson\" aria-errormessage=\"wpforms-4599-field_10-error\" required><\/div><div id=\"wpforms-4599-field_12-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_12\">Home Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-4599-field_12\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][12]\" aria-label=\"Home Phone\" aria-errormessage=\"wpforms-4599-field_12-error\" required><\/div><div id=\"wpforms-4599-field_14-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_14\">Cell Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-4599-field_14\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][14]\" aria-label=\"Cell Phone\" aria-errormessage=\"wpforms-4599-field_14-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-4599-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_11\">Relationship to child <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4599-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" placeholder=\"e.g., Mother\" aria-errormessage=\"wpforms-4599-field_11-error\" required><\/div><div id=\"wpforms-4599-field_13-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_13\">Work Phone<\/label><input type=\"tel\" id=\"wpforms-4599-field_13\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][13]\" aria-label=\"Work Phone\" aria-errormessage=\"wpforms-4599-field_13-error\" ><\/div><div id=\"wpforms-4599-field_15-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_15\">Email Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-4599-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" placeholder=\"e.g., laura.johnson@email.com\" spellcheck=\"false\" aria-errormessage=\"wpforms-4599-field_15-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-4599-field_24-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"24\"><h3 id=\"wpforms-4599-field_24\" aria-errormessage=\"wpforms-4599-field_24-error\">Secondary Emergency Contact<\/h3><\/div><div id=\"wpforms-4599-field_17-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"17\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-4599-field_18-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_18\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4599-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" placeholder=\"e.g., David Johnson\" aria-errormessage=\"wpforms-4599-field_18-error\" required><\/div><div id=\"wpforms-4599-field_19-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_19\">Home Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-4599-field_19\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][19]\" aria-label=\"Home Phone\" aria-errormessage=\"wpforms-4599-field_19-error\" required><\/div><div id=\"wpforms-4599-field_20-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_20\">Cell Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-4599-field_20\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][20]\" aria-label=\"Cell Phone\" aria-errormessage=\"wpforms-4599-field_20-error\" required><\/div><div id=\"wpforms-4599-field_16-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"16\"><h3 id=\"wpforms-4599-field_16\" aria-errormessage=\"wpforms-4599-field_16-error\">Additional Contact(s)<\/h3><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-4599-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_21\">Relationship to child <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4599-field_21\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][21]\" placeholder=\"e.g., Father\" aria-errormessage=\"wpforms-4599-field_21-error\" required><\/div><div id=\"wpforms-4599-field_22-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_22\">Work Phone<\/label><input type=\"tel\" id=\"wpforms-4599-field_22\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][22]\" aria-label=\"Work Phone\" aria-errormessage=\"wpforms-4599-field_22-error\" ><\/div><div id=\"wpforms-4599-field_23-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_23\">Email Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-4599-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" placeholder=\"e.g., david.johnson@email.com\" spellcheck=\"false\" aria-errormessage=\"wpforms-4599-field_23-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-4599-field_25-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"25\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-4599-field_26-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_26\">Name <\/label><input type=\"text\" id=\"wpforms-4599-field_26\" class=\"wpforms-field-medium\" name=\"wpforms[fields][26]\" placeholder=\"e.g., Sarah Smith\" aria-errormessage=\"wpforms-4599-field_26-error\" ><\/div><div id=\"wpforms-4599-field_28-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_28\">Phone Number<\/label><input type=\"tel\" id=\"wpforms-4599-field_28\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][28]\" aria-label=\"Phone Number\" aria-errormessage=\"wpforms-4599-field_28-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-4599-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_29\">Relationship to Student<\/label><input type=\"text\" id=\"wpforms-4599-field_29\" class=\"wpforms-field-medium\" name=\"wpforms[fields][29]\" placeholder=\"e.g., Aunt\" aria-errormessage=\"wpforms-4599-field_29-error\" ><\/div><div id=\"wpforms-4599-field_31-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_31\">Email Address<\/label><input type=\"email\" id=\"wpforms-4599-field_31\" class=\"wpforms-field-medium\" name=\"wpforms[fields][31]\" placeholder=\"e.g., sarah.smith@email.com\" spellcheck=\"false\" aria-errormessage=\"wpforms-4599-field_31-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-4599-field_32-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"32\"><h3 id=\"wpforms-4599-field_32\" aria-errormessage=\"wpforms-4599-field_32-error\">Medical Information<\/h3><\/div><div id=\"wpforms-4599-field_33-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"33\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-4599-field_34-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_34\">Known Allergies <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4599-field_34\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][34]\" placeholder=\"e.g., Peanuts, Bee Stings\" aria-errormessage=\"wpforms-4599-field_34-error\" required><\/div><div id=\"wpforms-4599-field_44-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_44\">Special Needs <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4599-field_44\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][44]\" placeholder=\"e.g., Learning, Behavioral, or Emotional \" aria-errormessage=\"wpforms-4599-field_44-error\" required><\/div><div id=\"wpforms-4599-field_36-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_36\">Primary Care Physician <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4599-field_36\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][36]\" placeholder=\"e.g., Dr. Alice Miller\" aria-errormessage=\"wpforms-4599-field_36-error\" required><\/div><div id=\"wpforms-4599-field_53-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_53\">Preferred Dentist  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4599-field_53\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][53]\" placeholder=\"e.g., Dr. Alice Miller\" aria-errormessage=\"wpforms-4599-field_53-error\" required><\/div><div id=\"wpforms-4599-field_55-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_55\">Preferred Hospital <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4599-field_55\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][55]\" placeholder=\"e.g., Dr. Alice Miller\" aria-errormessage=\"wpforms-4599-field_55-error\" required><\/div><div id=\"wpforms-4599-field_46-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_46\">Other information pertinent  to the health\/safety of your child <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-4599-field_46\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][46]\" aria-errormessage=\"wpforms-4599-field_46-error\" required><\/textarea><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-4599-field_35-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_35\">Medications <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4599-field_35\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][35]\" placeholder=\"e.g., Albuterol inhaler as needed\" aria-errormessage=\"wpforms-4599-field_35-error\" required><\/div><div id=\"wpforms-4599-field_45-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_45\">Other <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4599-field_45\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][45]\" placeholder=\"e.g., Diabetic, Anemic, etc.\" aria-errormessage=\"wpforms-4599-field_45-error\" required><\/div><div id=\"wpforms-4599-field_37-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_37\">Physician Phone Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-4599-field_37\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][37]\" aria-label=\"Physician Phone Number\" aria-errormessage=\"wpforms-4599-field_37-error\" required><\/div><div id=\"wpforms-4599-field_54-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_54\">Dentist Phone Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-4599-field_54\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][54]\" aria-label=\"Dentist Phone Number\" aria-errormessage=\"wpforms-4599-field_54-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-4599-field_38-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"38\"><h3 id=\"wpforms-4599-field_38\" aria-errormessage=\"wpforms-4599-field_38-error\">Consent and Acknowledgement<\/h3><\/div><div id=\"wpforms-4599-field_39-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"39\"><fieldset><legend class=\"wpforms-field-label\">Permission for Emergency Medical Care (Required) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-4599-field_39\" class=\"wpforms-field-required\" data-choice-limit=\"3\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4599-field_39_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][39][]\" value=\"I authorize parish officials to obtain emergency medical care for my child if necessary.  In the event reasonable attempts to contact me through the above listed contact numbers have been unsuccessful, I hereby give my consent for the above listed preferred physicians, or in the event that they are not available, by another licensed physician.  This authorization does not cover major surgery unless the medical opinions of two licensed physicians or dentists concurring in the necessity for such surgery are obtained before surgery is performed.\" aria-errormessage=\"wpforms-4599-field_39_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4599-field_39_1\">I authorize parish officials to obtain emergency medical care for my child if necessary.  In the event reasonable attempts to contact me through the above listed contact numbers have been unsuccessful, I hereby give my consent for the above listed preferred physicians, or in the event that they are not available, by another licensed physician.  This authorization does not cover major surgery unless the medical opinions of two licensed physicians or dentists concurring in the necessity for such surgery are obtained before surgery is performed.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-4599-field_51-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"51\"><fieldset><legend class=\"wpforms-field-label\">Additional Information<\/legend><ul id=\"wpforms-4599-field_51\" data-choice-limit=\"3\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4599-field_51_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][51][]\" value=\"I wish to inform you that additional medical information and the recommended course(s) of action (allergies, dietary restrictions, special conditions, etc.) are detailed on a separate printed sheet and will be provided to the authorized parish officials.\" aria-errormessage=\"wpforms-4599-field_51_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4599-field_51_1\">I wish to inform you that additional medical information and the recommended course(s) of action (allergies, dietary restrictions, special conditions, etc.) are detailed on a separate printed sheet and will be provided to the authorized parish officials.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-4599-field_52-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"52\"><fieldset><legend class=\"wpforms-field-label\">Special Request<\/legend><ul id=\"wpforms-4599-field_52\" data-choice-limit=\"3\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4599-field_52_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][52][]\" value=\"I would like to have a member of the program staff speak with me further regarding a medical concern or situation.  Please contact me at your convenience.\" aria-errormessage=\"wpforms-4599-field_52_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4599-field_52_1\">I would like to have a member of the program staff speak with me further regarding a medical concern or situation.  Please contact me at your convenience.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-4599-field_49-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"49\"><fieldset><legend class=\"wpforms-field-label\">[Grade 7-12 Only] <\/legend><ul id=\"wpforms-4599-field_49\" data-choice-limit=\"3\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4599-field_49_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][49][]\" value=\"I hereby grant permission for nonprescription medication (such as acetaminophen, decongestant, cough syrup) to be given to my son\/daughter, if requested by my son\/daughter and deemed advisable by an adult chaperone.\" aria-errormessage=\"wpforms-4599-field_49_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4599-field_49_1\">I hereby grant permission for nonprescription medication (such as acetaminophen, decongestant, cough syrup) to be given to my son\/daughter, if requested by my son\/daughter and deemed advisable by an adult chaperone.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-4599-field_50-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"50\"><fieldset><legend class=\"wpforms-field-label\">[Grade 7-12 Only]<\/legend><ul id=\"wpforms-4599-field_50\" data-choice-limit=\"3\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4599-field_50_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][50][]\" value=\"My son\/daughter is taking medications at present.  He\/she will bring all necessary medications and such medications will be well labeled.  The names of and the concise directions for taking such medications, including dosage and frequency of dosage will be provided to authorized parish officials.\" aria-errormessage=\"wpforms-4599-field_50_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4599-field_50_1\">My son\/daughter is taking medications at present.  He\/she will bring all necessary medications and such medications will be well labeled.  The names of and the concise directions for taking such medications, including dosage and frequency of dosage will be provided to authorized parish officials.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-4599-field_47-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_47\">Enter your name to confirm Consent and Ackowledgement of this Medical Authorization: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-4599-field_47\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][47]\" placeholder=\"John Smith\" aria-errormessage=\"wpforms-4599-field_47-error\" required><\/div>\t\t<div id=\"wpforms-4599-field_7-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"7\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-4599-field_7\" >Church Relationship Consent<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-4599-field_7\" class=\"wpforms-field-medium\" name=\"wpforms[fields][7]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-4599-field_41-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-4599-field_41\">Date of Signature <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4599-field_41\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][41][date]\" placeholder=\"MM\/DD\/YY\" aria-errormessage=\"wpforms-4599-field_41-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-4599-field_7-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-4599-field_7-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-4599-field_7-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"4599\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/stwilliamchampion.org\/index.php?rest_route=\/wp\/v2\/pages\/5019\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-4599\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/stwilliamchampion.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Trumbull North Catholic Community Emergency Medical Authorization Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Child Information Name * FirstLast Church at which your child will be attending Faith Formation *&#8212; Select Choice &#8212;St. RobertSt. ThomasSt. WilliamNone of the AboveDate of Birth *Grade [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":{"ocean_front_end_style_editor":"no","ocean_post_layout":"","ocean_both_sidebars_style":"","ocean_both_sidebars_content_width":0,"ocean_both_sidebars_sidebars_width":0,"ocean_sidebar":"","ocean_second_sidebar":"","ocean_disable_margins":"enable","ocean_add_body_class":"","ocean_shortcode_before_top_bar":"","ocean_shortcode_after_top_bar":"","ocean_shortcode_before_header":"","ocean_shortcode_after_header":"","ocean_has_shortcode":"","ocean_shortcode_after_title":"","ocean_shortcode_before_footer_widgets":"","ocean_shortcode_after_footer_widgets":"","ocean_shortcode_before_footer_bottom":"","ocean_shortcode_after_footer_bottom":"","ocean_display_top_bar":"default","ocean_display_header":"default","ocean_header_style":"","ocean_center_header_left_menu":"","ocean_custom_header_template":"","ocean_custom_logo":0,"ocean_custom_retina_logo":0,"ocean_custom_logo_max_width":0,"ocean_custom_logo_tablet_max_width":0,"ocean_custom_logo_mobile_max_width":0,"ocean_custom_logo_max_height":0,"ocean_custom_logo_tablet_max_height":0,"ocean_custom_logo_mobile_max_height":0,"ocean_header_custom_menu":"","ocean_menu_typo_font_family":"","ocean_menu_typo_font_subset":"","ocean_menu_typo_font_size":0,"ocean_menu_typo_font_size_tablet":0,"ocean_menu_typo_font_size_mobile":0,"ocean_menu_typo_font_size_unit":"px","ocean_menu_typo_font_weight":"","ocean_menu_typo_font_weight_tablet":"","ocean_menu_typo_font_weight_mobile":"","ocean_menu_typo_transform":"","ocean_menu_typo_transform_tablet":"","ocean_menu_typo_transform_mobile":"","ocean_menu_typo_line_height":0,"ocean_menu_typo_line_height_tablet":0,"ocean_menu_typo_line_height_mobile":0,"ocean_menu_typo_line_height_unit":"","ocean_menu_typo_spacing":0,"ocean_menu_typo_spacing_tablet":0,"ocean_menu_typo_spacing_mobile":0,"ocean_menu_typo_spacing_unit":"","ocean_menu_link_color":"","ocean_menu_link_color_hover":"","ocean_menu_link_color_active":"","ocean_menu_link_background":"","ocean_menu_link_hover_background":"","ocean_menu_link_active_background":"","ocean_menu_social_links_bg":"","ocean_menu_social_hover_links_bg":"","ocean_menu_social_links_color":"","ocean_menu_social_hover_links_color":"","ocean_disable_title":"default","ocean_disable_heading":"default","ocean_post_title":"","ocean_post_subheading":"","ocean_post_title_style":"","ocean_post_title_background_color":"","ocean_post_title_background":0,"ocean_post_title_bg_image_position":"","ocean_post_title_bg_image_attachment":"","ocean_post_title_bg_image_repeat":"","ocean_post_title_bg_image_size":"","ocean_post_title_height":0,"ocean_post_title_bg_overlay":0.5,"ocean_post_title_bg_overlay_color":"","ocean_disable_breadcrumbs":"default","ocean_breadcrumbs_color":"","ocean_breadcrumbs_separator_color":"","ocean_breadcrumbs_links_color":"","ocean_breadcrumbs_links_hover_color":"","ocean_display_footer_widgets":"default","ocean_display_footer_bottom":"default","ocean_custom_footer_template":"","footnotes":""},"class_list":["post-5019","page","type-page","status-publish","hentry","entry"],"_links":{"self":[{"href":"https:\/\/stwilliamchampion.org\/index.php?rest_route=\/wp\/v2\/pages\/5019","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stwilliamchampion.org\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/stwilliamchampion.org\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/stwilliamchampion.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/stwilliamchampion.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=5019"}],"version-history":[{"count":8,"href":"https:\/\/stwilliamchampion.org\/index.php?rest_route=\/wp\/v2\/pages\/5019\/revisions"}],"predecessor-version":[{"id":5056,"href":"https:\/\/stwilliamchampion.org\/index.php?rest_route=\/wp\/v2\/pages\/5019\/revisions\/5056"}],"wp:attachment":[{"href":"https:\/\/stwilliamchampion.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=5019"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}