2017 - 2018 Jr High Youth Ministry Registration
Please fill this online form to be registered for the 20145-2016 year of Jr high ministry! This will also secure your VERITAS sunglasses for the September 10th Kickoff!
Student First Name *
Your answer
Student Last Name *
Your answer
Student Grade *
Parish *
Your answer
Gender *
School *
Your answer
Student Email Address
Your answer
Student Cell Phone (for text message list)
Your answer
Parent Name *
Your answer
Parent Email Address *
Your answer
Parent Cell Phone
Your answer
Parent Home Phone
Your answer
Chronic Medical Conditions
Your answer
Medications
Your answer
Medical Insurance *
Your answer
Policy Number *
Your answer
Member’s Name *
Your answer
Phone Number
Your answer
Family Doctor
Your answer
Family Doctor Phone Number
Your answer
Parent Release and Indemnification - Must be read by parent A. As the above-named participant, I hereby register for and commit to attend the event listed on the signature form. I further agree to the terms of this Release and Indemnification Agreement, and I agree to comply with the Code of Behavior set forth below. B. As a parent or guardian of the above-named participant, I give my permission for my child or ward to register for and attend the activity as well as youth ministry activities taking place at St. Patrick Church as well as permission for my child’s image on photo or video to be used for promotional purposes. C. The undersigned release from all liability, and indemnify and hold harmless St. Patrick Church, the Diocese of Columbus, the Dominican Province of St. Joseph, and any employee or representative thereof from any and all liability, actions, causes of actions, claims, judgments, costs or expenses, arising out of or in any way related to injury, illness or loss incurred by the participant while participating in or traveling to or from this activity. *
Required
Code of Conduct - for participants - 1. Participants must stay and participate in the entire event. Participants may not leave the premises unless accompanied by an adult. 2. The possession or use of alcohol, tobacco, drugs, or weapons of any kind is not permitted. 3. Modesty in speech and dress is expected of all. Foul language is not tolerated. 4. Participants must heed any and all directions of activity staff. 5. Participants must respect the rights and property of others. Damage to or defacing of property will be the financial responsibility of the participants involved and the participant’s parents/legal guardians. 6. Failure to abide by this Code of Behavior may result in a request to parents/legal guardians, to transport offending participants from the premises, and the parents/legal guardians shall immediately comply with the request. *
Required
Student Tshirt Size *
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