Youth Ministry Registration First Name* Last Name* Nick Name**For Name Tags Gender Female Male Date of Birth* Grade* Parent/Guardian #1 Full Name* Parent/Guardian #2 Full Name Participant's Home Phone Number* Participant's Email Address* Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Parent/Guardian Email* Parent/Guardian Phone Number* Emergency Contact Phone Number**other than parent Emergency Contact Name**other than parent T-Shirt Size Small Medium Large X Large I am allergic to (medication/food/other):*If Not, WRITE "NONE"My child must take the following medications and will be bringing enough medication for (Indicate medication, dosage, frequency, etc. Medication must be given to your parish adult chaperone to hold/administer):*If Not, MUST WRITE "NONE"You should be aware of these special medical conditions of needs of my child (Dietary, medical, mental health, walking assistance, other conditions):*If Not, MUST WRITE "NONE"In the event that it comes to the attention of the ADW staff, its officers and agents or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever etc. I would like to be notified immediately: Yes No Insurance Name Policy Holder Policy # Group # Date of Last Tetanus Booster: In Case of Emergency Notify: Relationship to Youth: Daytime Phone: Evening Phone: YOUTH CODE OF BEHAVIOR*The following guidelines will ensure a fun and safe experience for all of us: 1. The possession of alcohol and illegal drugs is clearly prohibited and is cause for dismissal. 2. The Parish/Organization is responsible for the overall actions of the participants. 3. All participants, adults and youth, will be held to the highest Christian standards of morality. In the event that a behavior problem required disciplinary action, Archdiocese of Washington Adult chaperones or designee, along with the individual’s chaperone, will address the situation and make the necessary decision. As a member of Mother Seton Parish, I understand and agree to the Youth Code of Behavior. I also understand and agree that my parents or legal guardian will be notified at the time of any infractions requiring my dismissal from the event and that I will be sent home at my own and or parent’s/guardian’s expense. I agree to this policy.Participant Signature* Date Signed MM slash DD slash YYYY Consent to participate in the Faith Formation Program*I, (parent/guardian) undersigned, give permission for my son/daughter to attend the Mother Seton Youth Group – Seton Youth. It is understood that reasonable caution will be taken by those persons in charge to prevent injuries. In consideration of my child’s being permitted to participate in the Mother Seton Youth Group meetings at Mother Seton Parish on Sunday Evenings from 6-8pm, I personally and on behalf of my child, hereby release The Archdiocese of Washington; Wilton Gregory, Roman Catholic Archbishop of Washington; a Corporation Sole: the Catholic Youth Organization of Washington, DC and Metropolitan Area, Inc; the Office of Youth Ministry; their employees; volunteers, the coordinators and chaperones of Mother Seton Parish; from any liability for injuries or damages arising or resulting from participation in the Mother Seton Youth Group meetings , in and/or transportation to and there from. In the event that I cannot be reached, I hereby grant permission for my son/daughter to be evaluated, diagnosed, treated and/or medicated in accordance with standard medical practice by licensed medical personnel. Permission is hereby granted to the Archdiocese of Washington and Mother Seton Parish to use the photographs and quotations of my son/daughter to assist in community awareness, educational efforts, related public relations purposed that may include brochures, posters, website and print media from the Archdiocese of Washington. My child agrees to abide by all rules and regulations as outlined in the Youth Code of Behavior. I understand that the Office of Youth Ministry and the Archdiocese of Washington will not be held liable if my child fails to cooperate with said regulations and that any infractions of the rules may result in immediate dismissal from the Mother Seton Youth Group meetings. I agree to the privacy policy.Parent/Guardian Signature* Date Signed MM slash DD slash YYYY Registration Fees HiddenTuition Fees* Registration Fee- $10 Tuition Fees* Registration Fee - $10 Product Name Price: Total $0.00 Legal and SignatureConsent* I am the legal parent or legal guardian of the child(ren) and I certify that the information contained on this form is correct.Full Name of Parent/Legal Guardian* Date Signed MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
