DCYC 2019 Youth Registration Form
Diocese of Columbus

This online form must be completed by a parent or guardian and not another person on their behalf.

All registrations made after Noon on February 22 will be considered late and will not be guaranteed a t-shirt at the event.
Name of Parent/Guardian Completing this Form: *
Your answer
Parent/Guardian Email: *
Your answer
Name of Parish/School: *
First Name of Youth Participant: *
Your answer
Last Name of Youth Participant: *
Your answer
Participant Gender: *
Date of Birth: *
MM
/
DD
/
YYYY
Grade: *
T-shirt Size *
Registrations made after 10 AM, Monday, February 25 are not guaranteed a t-shirt. Additional t-shirts will be available on a first-come-first-serve basis for $5 each at the DCYC
Participant Mailing Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip code: *
Your answer
Participant Mobile Phone #:
Your answer
Mother/Guardian First Name: *
Your answer
Mother/Guardian Last Name: *
Your answer
Mother/Guardian Phone: *
Your answer
Father/Guardian First Name: *
Your answer
Father/Guardian Last Name: *
Your answer
Father/Guardian Phone: *
Your answer
Additional Emergency Contact Name: *
Your answer
Additional Emergency Contact Phone Number: *
Your answer
Chronic Conditions, special medical conditions, and/or physical limitations: *
(e.g. Epilepsy; Diabetes; Paraplegic; etc.)
Your answer
Allergic Reactions: *
(e.g. Food; Medications; Plants; etc.)
Your answer
Dietary Restrictions: *
Your answer
Current Medication: *
The Participant is taking medication at present. The Participant will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows:
Your answer
Medical Insurance:
Your answer
Policy Number:
Your answer
Insurance Member's Name:
Your answer
Insurance Phone #:
Your answer
Family Doctor Name:
Your answer
Family Doctor Phone #:
Your answer
Non-Prescription Medication *
Consent to Release of Photographs *
Do you hereby consent to the release of photographs and name of the Participant to be used by the Diocese of Columbus, and its parishes and schools, for future promotional programs of the Diocese, and its parishes and schools?
Permission, Release and Indemnification, and Code of Behavior *
I have read and agree to all the terms and conditions list in the Permission, Release and Indemnification, and Code of Behavior found here: https://columbuscatholic.org/documents/2019/1/DCYC%20Permission%20Release%20and%20Idemnification%20and%20Code%20of%20Behavior.pdf
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