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Saint Jude Youth - Teen Application and Waivers for 2017-18 Academic Year
This form covers the dates from 7/17 to 7/18. You do not need to complete a new form unless your information changes.

THIS FORM CAN ONLY BE COMPLETED BY A PARENT/GUARDIAN

The first email address below must be a valid parent email address. (You will receive an email confirmation of this form.)

Email address *
First Name of Child/Minor *
Your answer
Last Name of Child/Minor *
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Please select your child's grade level for the 17-18 academic year. *
FYI: 6th-8th grade is Junior Youth Group (JYG)... 9th-12th grade is Senior Youth Group (SYG)
Emergency Contact/Parent Name *
Can list more than one Emergency contact separated by comma. (Jane Smith, John Smith)
Your answer
Emergency Contact Cell Number *
Can list more than one Emergency contact number separated by comma. (203-222-1111, 203-111-2222)
Your answer
Can we contact you via text at this number?
Email Address for Teen (or secondary parent email)
Not required. Please do not repeat same email address as parent
Your answer
Please provide us with any medical, dietary, or other information that you feel the SJY staff and volunteers should be aware of.
Otherwise, leave this section blank.
Your answer
The following items pertain to Safe Environment Requirements. Please read carefully.
MEDICAL RELEASE: I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend Saint Jude Catholic Church (Monroe, CT) and the Saint Jude Youth Group (Monroe, CT), its officers, directors, employees and agents, and the Diocese of Bridgeport, its employees and agents, chaperones, or representatives associated with the event, from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish/school, its officers, directors and agents, and the Diocese of Bridgeport, its employees and agents and chaperones, or representative associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/school or the Diocese of Bridgeport. *
By checking the box below you are affirming that you have read, understand, and agree to all terms outlined in the "Medical Release" Section.
Required
COMMUNICATIONS WAIVER 1: I give permission to Saint Jude Parish (Monroe, CT), the Saint Jude Youth Group (Monroe, CT), the Diocese of Bridgeport, as well as all agents of the aforementioned to photograph, videotape, and/or film my child and to use his or her image in photographs, video, and/or film for the purpose of promoting the mission, activities, and programs of Saint Jude Parish (Monroe, CT), the Saint Jude Youth Group (Monroe, CT), and the Diocese of Bridgeport. I understand that I and my child are not entitled to any compensation or rights in these materials, and I release the Diocese of Bridgeport or any of its agents from any liability for the use of my child’s image for the above stated purposes. I further understand that my child's photograph, videotape, and/or film may be used for future publications or advertisements or social media updates for Saint Jude Parish (Monroe, CT), the Saint Jude Youth Group (Monroe, CT), and the Diocese of Bridgeport. *
By checking the box below you are affirming that you have read, understand, and agree to all terms outlined in the "Communications Waiver 1" Section.
Required
COMMUNICATIONS WAIVER 2: I give permission to Saint Jude Parish (Monroe, CT), the Saint Jude Youth Group (Monroe, CT), the Diocese of Bridgeport as well as all agents of the aforementioned to communicate with my teen via e-mail, text messages, phone calls, as well as Facebook, Twitter, Instagram and any other social media. *
By checking the box below you are affirming that you have read, understand, and agree to all terms outlined in the "Communications Waiver 2" Section.
Required
CODE OF CONDUCT FOR TEENS (MINORS): I will remember that I represent not just myself, but also the Saint Jude Youth Community and will strive at all times to provide a favorable impression. I will joyfully participate in all aspects of our events including Mass, Adoration, prayer, planned activities, service projects, and group sessions. I will be responsible for my own behavior. I will show respect at all times to our clergy, youth minister, adult volunteers, and all other members of youth group.I will not intimidate or bully, either physically or emotionally, any other participant. I will refrain from using obscene or insensitive humor or language. I will not engage in any form of vandalism or taking anything which does not belong to me from the parish facilities or other locations we may be at. I will be responsible for the condition of all facilities used by me during youth group events and agree to pay the cost of any repair, cleaning, or replacement which is necessary because of my conduct.I will not be alone with a member of the opposite sex in a private setting or engage in inappropriate behavior. I will not enter or attempt to enter any areas which are marked as off-limits or which any group leader has indicated is off-limits. I will stay within certain designated areas and I will never wander off anywhere alone while at the youth group events. I will not use tobacco, alcoholic beverages or illegal drugs at any time during youth group events. I understand that my violation of any of these rules can result in any consequence that my youth minister as well as other persons in positions of authority consider appropriate, which could range from a verbal warning to expulsion from the youth group or youth group events. I understand that repeated verbal warnings for any infractions will also result in expulsion. If I am sent home, I understand that my parent(s)/guardian(s) and I will be responsible for any and all costs incurred in my trip home. *
By checking the box below you are affirming that you have read, understand, and agree to all terms outlined in the “Code of Conduct" Section.
Required
PARENT/GUARDIAN: By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge, and that you have read and understand all releases and waivers. *
Your answer
A copy of your responses will be emailed to the address you provided.
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