2019/2020 High School Youth Ministry Registration for St Thomas/St John
CHILD INFORMATION
Child's First Name *
Your answer
Child's Last Name *
Your answer
Gender *
Birth Date *
MM
/
DD
/
YYYY
Year in School During 2019-2020 *
School Child Attends *
Your answer
Full Home Address *
Your answer
Student Email Address: *
Your answer
Allergies / Health / Learning Challenges *
Your answer
PARENT INFORMATION
Mother/Guardian 1 First and Last Name *
Your answer
Father/Guardian 2 First and Last Name *
Your answer
Mother/Guardian 1 Email Address *
Your answer
Father/Guardian 2 Email Address *
Your answer
Mother/Guardian 1 Phone Number *
Your answer
Father/Guardian 2 Phone Number *
Your answer
PROGRAM CHOICE
What Program(s) Will Your Child Be Joining? *
Required
EMERGENCY CONTACT INFORMATION
Name of Emergency Contact (not parents/guardians) *
Your answer
Phone Number of Emergency Contact *
Your answer
PERMISSION AND DISCLAIMERS
Included in this section are Participation Release Form, Diocese of Lansing - Media Release Form, Communication Release Form. The full language or a hard copy can be sent to you on request (jhamilton@elcatholics.org). Your YES will act as a binding personal signature and date for the following:
(My student’s name as indicated above) has my permission to participate in activities in the St. Thomas Aquinas and St. John Church and Student Center Parish Religious Education and Youth Ministry Program during the 2018/2019 school year. I understand that all activities are sponsored by the parish and supervised by parish volunteers and/or staff. Transportation to and from the parish is the parents’ or guardian’s responsibility. *
I give permission to the Diocese of Lansing and St Thomas / St John to use the image of my child, (students name as indicated above) in its promotional materials. I understand that these materials maybe presented in any format, including paper, electronic, and all other media. Neither my child nor I will receive any money in exchange for this permission; the Diocese of Lansing will own the copyright to these materials,and I waive on behalf of my child the right to sue for use of my child’s image in good faith by the Diocese of Lansing. *
I understand that the staff of St. Thomas Aquinas Parish/St. John may be communicating with members of our family. If you, as parent or guardian, have any particular boundaries of which we should be aware, or if there are any common media that you want us not to use in communicating with you or your child, please let us know in the "other" answer. *
HEALTH HISTORY FORM
I understand that by submitting this form electronically, my typed full name, acts as my signature. *
Medical Conditions *
If your child does have a condition, provide a full explanation in this box and type in your full name at the end to act as your signature. *
Your answer
PERMISSION FOR DISCLOSURE AND EMERGENCY MEDICAL TREATMENT: The parish has my permission, in an emergency when parents or guardians cannot be contacted, to take my child to a hospital emergency room. The hospital and its medical staff have my authorization to provide treatment that a physician deems necessary for the well-being of my child. I will be contacted as soon as possible and will be advised prior to any further treatment by the hospital or doctor. I understand and agree that I will be responsible for the emergency medical charges. I understand that by entering my full name, this acts as my signature. *
Please enter your NAME and today's DATE
Your answer
Insurance Provider / Health Plan *
Your answer
Health Plan Number *
Your answer
Registration Donation
Suggested Donation Per Child in High School Youth Ministry is a minimum of $25 for the whole year. Donations can be made in person, by check, or online. For students that are unable to make a donation, full scholarships are always provided - we are happy to have everyone join Youth Ministry, regardless of cost!

For Youth Ministry this year, we will not be accessing a regular "fee" per student as has been done in past years. Instead, we will ask all those who register to make the donation amount you are comfortable making to support our ministry. Your donation will be used to purchase food and snacks at all Youth Groups, pay speakers stipends for talks, pay for materials and videos and registrations, and help support our retreat ministries. Please prayerfully consider what you donation you are able to make to support our Youth Ministry.

Payment: *
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