UCYM Evanston Soccer Festival Team
James Holzhauer-Chuckas, ObSB
Regional Director of Youth Ministry
847-864-1185 x26 | JAMESHC@ucym.org
First & Last Name of Teen Participant *
Your answer
T-shirt Size *
Cell Phone # for Teen *
Your answer
Parent/Guardian Cell Phone # for EMERGENCIES *
Your answer
An adult over the age of 18 and is a responsible party of the teen participant must sign. Please read carefully!
COMMUNICATION: [IMPORTANT, PLEASE READ CAREFULLY]: I hereby give James Holzhauer-Chuckas, ObSB (Regional Director of Youth Ministry) and other any Archdiocesan child protection-compliant adult volunteer on the Youth Ministry Team permission to communicate with my teenager through text message and other online communications tools: GroupMe, Facebook, Twitter, Instagram, and Email to discuss meetings, formation, and other matters pertaining strictly to Youth Ministry. I acknowledge and agree that if I have any concerns regarding questionable activity that I will contact the undersigned staff members and that they may involve the Pastor. Please type FULL NAME as an electronic signature. *
MEDICAL AUTHORIZATIONS: In the event that the undersigned cannot be reached, and in the judgment of the responsible adults or other appropriate staff members accompanying the group, if there is a necessity for immediate examination and/or treatment of my child I hereby authorize any of the aforesaid personnel to obtain for my child such medical services as are deemed necessary. I GRANT PERMISSION for the Youth Council personnel to administer non-prescription drugs as advised by the Youth Director as needed for my teen (aspirin, ibuprofen, etc.) *
PHOTO RELEASE: I AUTHORIZE the Parishes of the Evanston & Skokie Archdiocesan Grouping to use photographs/videos of my child strictly for church-related productions, publications, etc. *
LIABILITY WAIVER: I hereby give permission for my teen to participate in the Evanston Soccer Festival on behalf of United Catholic Youth Ministries of Evanston & Skokie. I hereby release and indemnify the Archdiocese of Chicago, St. Nicholas Church for this event, its staff and volunteers, Ridgeville Park District and its staff and volunteers; and the Catholic Bishop of Chicago, a corporation sole, from any and all liability arising from claims of any kind or nature whatsoever from my child’s participation in the program. I understand that if my child violates any laws regarding possession of alcohol or drugs, or rules governing the program, I will be called and notified about the situation and/or arrangements made to send my child home at my expense during any event. Please write FULL NAME AND RELATION TO TEEN of adult signing for teen participant as an electronic signature. *
Your answer
Thank You!
We look forward to having your teen play on our team!
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