2016-2017 High School Youth Ministry Registration
For students to participate in onsite and off site programming throughout the academic year, the Diocese of Columbus requires a release for students. This ensures staff and adult volunteers are able to contact you if the need arises. This also ensures the youth minister, Kristin Collura, is aware of allergies, medications, and any other pertinent information while your child is in the care of St. Agatha Youth Group

*Please note: You only have to fill out one consent form per year, unless you participate in a Diocesan sponsored event!
Only a simple permission form will be needed for future Saint Agatha Youth Group Sponsored events.

Student's First Name
Your answer
Student's Last Name
Your answer
Student's Birthday
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Student's Gender
Student's Email (optional)
Your answer
Student's Grade, Fall 2016
Student's School
Student's Home Parish
Parent 1 First and Last Name
Your answer
Parent 1 Cotact Phone Number
Your answer
Parent 1 Email
Your answer
Parent 2 First and Last Name (optional)
Your answer
Parent 2 Contact Phone Number (optional)
Your answer
Parent 2 Email (optional)
Your answer
Other Emergency Contact Name (optional)
Your answer
Other Emergency Contact Phone Number (optional)
Your answer
I am the parent/guardian of the named student above and grant permission for the student to participate in Saint Agatha's Youth Group
Social Media: I am aware that Saint Agatha Youth Ministry uses the following platforms of communication to connect with students, parents, and volunteers: Email, Remind (safe texting), Facebook, and Instagram.
Required
Photo Release: By giving photo release consent, you are consenting to allow Saint Agatha Youth Group use photo and/or video images of your child on Saint Agatha promotional materials without the use of a name.
Does your child have any allergies? If so, please list:
Your answer
Does your child have any chronic conditions (e.g. Epilepsy; Diabetes) If so, please list:
Your answer
Does your child self-carry any medication? If so, please list.
Your answer
Non-prescription medication permission:
In the event of an emergency, I give permission to transport the student to a hospital for emergency medical or surgical treatment
--- EVENT OVER NO LONGER REQUIRED TO ANSWER --- I give my consent for the above named student to participate in the Youth Ministry fall outing October 23, The Maize (8657 Axe Handle Rd, Milford Center, OH 43045) if s/he chooses. I understand it will be paid for via cash or check before the scheduled event: Events sponsored by youth ministry will follow the diocesan policy of transportation, abiding by the safe environment driving policy.
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.
Required
Parent/Guardian's Electronic Signature
Your answer
Today's Date
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