Loading...

Registration is required for participation in Youth Ministry.  It is mandatory for us to have the teen's contact information, health concerns, and signed waivers on file for you to leave your teen in our care.  Each teen must be registered separately.

We, the parents/guardians do hereby give our permission for him/her to attend Youth Ministry for the 2019-2020 Catechetical Year. This release covers all Youth Ministry /Youth Ministry related events at  Saint Benedict, Marguerite and the Partner Parish of Our Lady of Grace.

We do hereby release and forever discharge the Diocese of Greensburg and designated chaperones from any/all actions or suits in law or equity which we might hereafter have by reasons of injuries sustained by our son/daughter participating in the above mentioned activity. 

PHOTOGRAPHIC RELEASE LETTER

I hereby grant to the Diocese of Greensburg, Pennsylvania, and its respective licensees, successors and assigns, the right and permission, with respect to those photographs taken of me or the minor named below on whose behalf I am signing, and with respect to any printed or electronic matter in connection therewith, to do the following: To include such photographs on the Diocese of Greensburg website and on print material (names of minors are not used for web or print media/publications without prior consent)

I hereby release, discharge and agree to indemnify and hold harmless the Diocese of Greensburg and its legal representatives, licensees, successor and assigns, from all claims and demands whatsoever arising out of or in connection with the foregoing, and waive any right to inspect or approve the same.

I hereby certify that I am the parent and/or guardian of a minor under the age of eighteen years, and hereby consent on behalf of said minor to the use of any of the photographs taken of said minor pursuant to the terms set forth in this Photographic Release, including, without limitation, the release, discharge and hold harmless provisions thereof.

Date: September 23, 2019

Please select who will be participating...
Minor
Continue
First Teen's Name

First Name*

Middle Name

Last Name*

Phone*
First Teen's Date of Birth*
First Teen's Information

School Attending *
Grade Level for Fall 2019-2020*

Teen's Email

Teen's Cell Phone
Are you registered at Saint Benedict?*
Yes
No

If no, what is your parish of registration?
Sacraments the child has received (check all that apply) *
Baptism
First Holy Communion
Confirmation
None
My child has a food allergy*
No
Yes

If answered yes to food allergy, please list the allergies
My child has a learning disability*
No
Yes

If answered yes to learning disability, please list ALL learning disabilities
My child has a medical condition*
No
Yes

If answered yes to medical condition, please list ALL medical conditions

Please list any special accommodations that your child may need
Can this person be given the following by the medical coordinator? (please check all)
Iburprofen
Acetaminophen
Benedryl
Pepto Bismal
Immodium
First Teen's Signature*
Teen's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Father/Primary Guardian Information

First Name

Last Name

Address (if different from Participant)

Email

Home Phone (if different from participant)

Cell Phone
Is this the primary adult contact?*
No
Yes
Mother/Primary Guardian Information

First Name

Last Name

Address (if different from Participant)

Email

Home Phone (if different from Participant)

Cell Phone
Is this the primary adult contact?*
No
Yes
Custody/Divorce/Separation Situations

Are there any concerns/situations that we should be aware of pertaining to the safety/security of this child?

Is there anyone who is NOT permitted to be with your child?
Are you interested in helping?
I would like to.....(please check all that apply)
serve on the Youth Ministry Core Team
help chaperone events
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

School Attending *
Grade Level for Fall 2019-2020*

Teen's Email

Teen's Cell Phone
Are you registered at Saint Benedict?*
Yes
No

If no, what is your parish of registration?
Sacraments the child has received (check all that apply) *
Baptism
First Holy Communion
Confirmation
None
My child has a food allergy*
No
Yes

If answered yes to food allergy, please list the allergies
My child has a learning disability*
No
Yes

If answered yes to learning disability, please list ALL learning disabilities
My child has a medical condition*
No
Yes

If answered yes to medical condition, please list ALL medical conditions

Please list any special accommodations that your child may need
Can this person be given the following by the medical coordinator? (please check all)
Iburprofen
Acetaminophen
Benedryl
Pepto Bismal
Immodium
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver