Youth Ministry Registration

Youth First Name:

Middle Name:

Last Name:

Nickname (if any):

Address:

City:

Zip:

Sex:

Birthdate:

School:

Grade:

Expected Graduation Year:

T-Shirt Size:

Youth's E-mail:

Youth's Home Phone:

Youth's Cell Phone:

Extracurricular Activities:

Attended CCD/Confirmation class last year?

Yes

No

Attended St. Pius X Life Teen or Edge last year?

Yes

No

Mail should be addressed to:

Parents

Mother

Father

Other

If other please specify:

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Father Title

FATHER

First & Last Name:

Phone #:

Address:

E-mail Address:

Mother Title

MOTHER

First & Last Name:

Phone #:

Address:

E-mail Address:

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Emergency Contacts Title

EMERGENCY CONTACTS

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In the event of an emergency, if we cannot get in contact with one of the parents or guardians indicated above, please indicate who we should contact below:

Emergency Contact #1:

Relationship to Youth:

Phone #:

Emergency Contact #2:

Relationship to Youth:

Phone #:

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Medical Information Title

MEDICAL INFORMATION

Doctor's Name:

Phone #:

Insurance Co. Name:

Medical Insurance ID #:

Group #:

Insurance Cardholder's Name:

Participant's allergies, if any, including medication and foods:

Participant's chronic medical problems (if any):

Partisipant's other physical restrictions (if any):

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Sacraments Title

SACRAMENTS RECIEVED

Baptism:

Yes

No

Date Recieved:

Place:

Reconciliation:

Yes

No

Date Recieved:

Place

Holy Communion:

Yes

No

Date Recieved:

Place

Confirmation:

Yes

No

Date Recieved:

Place:

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Parent/Guardian Duties Title

PARENT/GUARDIAN INVOLVEMENT

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EDGE parents are asked to provide a snack on Wednesday evenings: Please indicate your preference for 2 months that are best for us to call on you.

1st preference (month):

2nd preference (month)

No Preference

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LIFE TEEN parents are asked to donate funds for meals on Sunday evenings. Please indicate your preference for 2 months that are best for us to call on you.

1st preference (month)

2nd preference (month)

No preference

No Preference

Volunteers

WE NEED ADULT VOLUNTEERS! Please indicate how you can help:

Volunteer Opportunities

EDGE Small Group Leader

Life Teen Small Group Leader

Social Media

Photography

Meal/Snack Volunteer

Retreat Team

Music Team

Setup/Clean Up

Free Text

If you have any questions about volunteering with one of our youth ministry programs, call Brandon in the church office or e-mail blutz@stpiusxcc.org for more information.

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Liability Waiver Title

LIABILITY WAIVER

Liability Text

By clicking below, I agree on behalf of myself, my child’s other parent if known or living, my child named herein, our heirs, successors, and assigns, to release and hold harmless and defend the Diocese of Corpus Christi, St. Pius X Catholic Church (its pastors, youth minister, principal, other agents, etc.) or any representatives associated with any ongoing scheduled activities from all damages, claims, suits, expenses and payments for injury to my child and/or property, including all damages, claims, suits, expenses and payments resulting from the negligence of the Diocese of Corpus Christi, St. Pius X Catholic Church, and/or their officers, directors and employees.

Opt-In

I agree.

Parent/ Guardian Name

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Photography Consent Title

PHOTOGRAPHY CONSENT

Photo Consent Text

As parent/guardian, I understand that photos and video (individual and group) will be taken during youth group events, and I give permission for my son’s/daughter’s picture to be used for printed or online promotional materials.

Photo Consent

I give permission.

I do not give permission.

Parent/Guardian Name

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Medical Consent Title

MEDICAL CONSENT

Medical Consent Text

I hereby warrant to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of this participant.

Emergency Medical Treatment

In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor.

Medications

My child will bring all such medications, well labeled, that are necessary. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency are as follows:

Medication(s):

Administer/Dosage:

Free Text

Of the following statements pertaining to medical matters, check only those in accordance with your wishes:

Medical Consent

I hereby DO NOT GRANT PERMISSION for medication of any type, whether prescription or nonprescription, to be administered to my child unless the situation is life threatening and emergency treatment is required.

I hereby GRANT PERMISSION for nonprescription medication (Tylenol, throat lozenges, cough syrup, etc.) to be given to my child, if deemed advisable. I understand that Aspirin will not be given to my son/daughter.

Parent/Guardian Name

Youth Ministry/Confirmation Registration

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