Youth Ministry Combined Form Combined Registration/Medical Release/Permission Form I. General InformationStudent's Name* First Middle Initial Last Address* Street Address Address Line 2 City 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 State ZIP Code Student's Email* Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home Phone*Gender* Male Female Parish/group with which you are registered?* Grade 6 7 8 9 10 11 12 Mother's/Guardian's Name* First Last Father's/Guardian's Name* First Last Parent's Email Please provide e-mail address for a parent or Guardian.ADA Considerations Wheelchair Access/ Mobility Impaired Blind/Visually Impaired Hearing Impaired/Interpretation Needed Hearing Impaired/Interpretation NOT Needed Please note: All areas utilized are not ADA accessible. Contact the parish office if special arrangements need to be made.Additional Emergency ContactIf parents/guardians are unavailableName of Additional Emergency Contact* First Last Relationship to Student* Please list your relationship to the studentAdditional Emergency Contact Phone Number*Additional Emergency Contact Phone Type Home Cell Work II. Youth AgreementI understand that my participation in this program requires compliance with specific regulations for this event. I agree to abide by all rules and regulations set forth. Any infraction of the rules or regulations, including, but not limited to, the possession of alcohol, drugs, or weapons may cause my dismissal from the program. If I should be dismissed, I understand that my parents will be contacted to arrange for my immediate transportation home.Youth's Signature*III. Parental AgreementI, the parent/guardian of the youth listed above who is less than nineteen years of age, grant permission for my daughter/son to participate in the youth ministry events at Blessed Sacrament and/or Saint Elizabeth Ann Seton Catholic Churches. By allowing my child to participate in the said program, I hereby assume all risk of accident or harm arising or growing out of, directly or indirectly, any incident of any kind occurring during the course of such program to my child and do hereby release and discharge the Bishop of the Diocese of Youngstown, and Blessed Sacrament and/or Saint Elizabeth Ann Seton Catholic Churches and the agents, associates, and employees of the Bishop and parish/school who have organized or participated in the supervision of such program from all claims, demands, suits, causes or actions, rights, costs, expenses, and any compensations whatsoever which may occur to my family and its members during or resulting from participating in the program mentioned. I understand fully that this permission form is good for one (1) year and will notify the parish youth minister of any changes to my daughter/sons information.Parent's Signature*I am aware of the particulars of the said program including the times, costs, and adults chaperoning and/or transporting my child for the program and have clarified any concerns I may have with the coordinating adult in charge. I agree that my son/daughter shall abide by the rules and all regulations of the program including in regards alcoholic beverages, drugs, and weapons. I agree that if my son/daughter fails to abide by the regulations set forth, he/she may be dismissed from the program and I will need to arrange for his/her immediate transportation home at my expense. Parent's Signature* I understand that any photographs or video taken at this event may be used in parish or diocesan publicity.Parent's Signature*I hereby authorize the parish/group to communicate directly with my child, or indirectly through me, via: cell phone text message, Facebook and Instagram under the name of Blessed Sacrament Catholic Church and/or Saint Elizabeth Ann Seton Catholic Church and via email from dmarie@warrencatholic.org.Parent's Signature*IV. Medical InformationPlease check and sign only those below which are in accordance with your wishesPermission for Medical Care Permission Granted Permission Declined In the event of an emergency and the Parent/Guardian is unavailable.Medical Treatment Permission GrantedIn the event of an emergency, I hereby grant permission to transport my son/daughter and obtain emergency medical or surgical treatment from a licensed physician, hospital, or medical clinic. I hereby authorize medical personnel to release necessary information about his/her care to the parish or school group leaders(s) named below.Name of Person to which medical information is authorized to be released First Last I wish to be advised prior to further treatment by the hospital or doctor. In the event I cannot be reached, please contact the Additional Emergency Contact listed above.Family Physician* Family Physician Phone*Medical Insurance Coverage* Covered by Insurance NOT Covered by Insurance Medical Insurance policy Information List Policy # and Company Issued ByMy son/daughter does not have medical coverage and I assume responsibility for the cost of hospitalization and medical care for my son/daughter.Signature of Parent / Guardian*Medical Treatment Permission DeclinedI hereby warrant that to the best of my knowledge, my son/daughter is in good health. I do not want any medical treatment to be given to my son/daughter under any circumstances. I hereby assume all responsibility for the health and well being of my son/daughter and release from responsibility the Bishop of the Diocese of Youngstown, and Blessed Sacrament and/or Saint Elizabeth Ann Seton Catholic Churches, and the agents, associates, and employees of the Bishop and parish who have organized or participated in the supervision of such program.Signature of Parent / Guardian*V. MiscellaneousMedication Administration Permission* No medication of any type whether prescription or nonprescription may be administered to my child unless the situation is life threatening and emergency treatment is required. I hereby grant permission for nonprescription medication (such as acetaminophen, decongestant, cough syrup) to be given to my son/daughter, if requested by my child and deemed advisable by an adult chaperone. Approve or decline administration of medications.Signature of Parent / Guardian*Allergies / Medical Conditions*I wish to inform you of the following additional medical information and the recommended course of action (allergies, dietary restrictions, special conditions, etc.)Signature of Parent / Guardian*Medications Being Taken by the Student*My son/daughter is taking medications at present. He/she will bring all necessary medications and such medications will be well labeled. The names of and concise directions for taking such medications, including dosage and frequency of dosage are as follows:Signature of Parent / Guardian*Please Contact Parent/Guardian*I would like to have a member of the program staff speak with me further regarding a medical concern or situation noted on this form. Here is the best way to contact me to contact me.Youth Photo Release Form Please also fill-out the Youth Photo Release Form by: 1. Copy the website address in the box above 2. Click the box “Submit” to complete this form 3. Paste the copied address into your browser and hit Enter to open the second form CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
