Registration for St. Brigid Middle School Youth Group
2017 - 2018
Student Information
Please complete the information below on your child.
Student First Name *
Your answer
Student Last Name *
Your answer
Grade Fall 2017 *
School *
Your answer
Student Birthdate *
Your answer
T-shirt Size *
Medical Information
We will be serving food at each meeting. Please answer the questions below.
Does your child have any dietary concerns?
Your answer
Does your child have any chronic medical concerns?
Your answer
Does your child have any life-threatening allergies?
Your answer
Does your child take any medications related to any of the above?
Your answer
By checking this box, I agree that in case of emergency, I authorize St. Brigid of Kildare Youth Ministry to take whatever action in deems necessary in the best interest of my child. *
Selecting an option below constitutes your digital signature
By checking this box, I agree to allow St. Brigid to use photo images of my child on St Brigid Youth Ministry promotional materials and website without the use of a name. *
Selecting an option below constitutes your digital signature
Parent Information
Parent 1 First Name *
Your answer
Parent 1 Last Name *
Your answer
Parent 1 Phone *
Your answer
Parent 1 Email *
Your answer
Parent 1 Address *
Your answer
Parent 2 First Name
Your answer
Parent 2 Last Name
Your answer
Parent 2 Phone
Your answer
Parent 2 Email (leave blank if same)
Your answer
Parent 2 Address (leave blank if same)
Your answer
Emergency Contact:
Emergency Contact Name *
Your answer
Emergency Contact Phone *
Your answer
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