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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.

A family may register all of their teens on one waiver. 

PARISH NAME: The Partner Parishes of Our Lady of Grace and Saint Benedict
PARISH ADDRESS:  1011 Mount Pleasant Road Greensburg PA 15601 / 260Bruno Road Greensburg PA 15601
EVENT SUPERVISOR: Katrina Coleman 
EVENT: Weekly Youth Ministry and On-Site Parish/Youth Ministry Events
              All off-site events, not held at the 2 locations listed above, will require a seperate permission form. 
TRANSPORTATION: NONE
COST: NONE (extra events, with seperate permission forms may incur a fee)

I hereby consent to participation for the above named child(ren) in the event described above. I understand that if stated, this event will take place away from the Church grounds and that my child(ren) will be under the supervision of the designated parish employee on the stated date(s). I further consent to the conditions stated above on participation in this event, including the method of transportation. In case of emergency, we give permission for our child(ren) to be treated at a hospital and/or by a medical doctor.

In consideration for providing my child(ren) the opportunity to attend formation and parish activities and any related transportation to and from the parish, both my child(ren) and I voluntarily agree to release and agree to hold PARISH AND DIOCESE OF GREENSBURG harmless from, and waive on behalf of myself/my child(ren), my heirs, and any personal representatives, any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself/my child(ren) that may be caused by any act, or failure to act of the PARISH AND DIOCESE OF GREENSBURG or that may otherwise arise in any way in connection with my child(ren)’s attendance at a parish/diocesan event to the fullest extent allowed by law.

I understand that this release discharges the PARISH, AND DIOCESE OF GREENSBURG from any liability or claim that I/my child(ren), my heirs, or any personal representatives may have against the parish/ diocese with respect to any bodily injury, illness, death, or medical treatment that may arise from, or in connection to, my child(ren)’s attendance at the parish or event.

This liability waiver and release extends to the PARISH, AND DIOCESE OF GREENSBURG together with its clergy, staff, and volunteers.

I certify and represent that I have the legal authority to waive, discharge, release, and hold harmless the released parties on behalf of myself and the above-named student.


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 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 the above said minor/s 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: June 28, 2022

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 2021-2022*

Teen's Email

Teen's Cell Phone
My parish of registration is:*
Our Lady of Grace
Saint Benedict
Other

If other, 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 non-food allergy:*
No
Yes

If yes, please list the allergy/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*
Second Teen's Name

First Name*

Middle Name

Last Name*
Second Teen's Date of Birth*
Second Teen's Information

School Attending *
Grade Level for Fall 2021-2022*

Teen's Email

Teen's Cell Phone
My parish of registration is:*
Our Lady of Grace
Saint Benedict
Other

If other, 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 non-food allergy:*
No
Yes

If yes, please list the allergy/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
Third Teen's Name

First Name*

Middle Name

Last Name*
Third Teen's Date of Birth*
Third Teen's Information

School Attending *
Grade Level for Fall 2021-2022*

Teen's Email

Teen's Cell Phone
My parish of registration is:*
Our Lady of Grace
Saint Benedict
Other

If other, 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 non-food allergy:*
No
Yes

If yes, please list the allergy/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
Fourth Teen's Name

First Name*

Middle Name

Last Name*
Fourth Teen's Date of Birth*
Fourth Teen's Information

School Attending *
Grade Level for Fall 2021-2022*

Teen's Email

Teen's Cell Phone
My parish of registration is:*
Our Lady of Grace
Saint Benedict
Other

If other, 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 non-food allergy:*
No
Yes

If yes, please list the allergy/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
Fifth Teen's Name

First Name*

Middle Name

Last Name*
Fifth Teen's Date of Birth*
Fifth Teen's Information

School Attending *
Grade Level for Fall 2021-2022*

Teen's Email

Teen's Cell Phone
My parish of registration is:*
Our Lady of Grace
Saint Benedict
Other

If other, 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 non-food allergy:*
No
Yes

If yes, please list the allergy/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
Sixth Teen's Name

First Name*

Middle Name

Last Name*
Sixth Teen's Date of Birth*
Sixth Teen's Information

School Attending *
Grade Level for Fall 2021-2022*

Teen's Email

Teen's Cell Phone
My parish of registration is:*
Our Lady of Grace
Saint Benedict
Other

If other, 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 non-food allergy:*
No
Yes

If yes, please list the allergy/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
Seventh Teen's Name

First Name*

Middle Name

Last Name*
Seventh Teen's Date of Birth*
Seventh Teen's Information

School Attending *
Grade Level for Fall 2021-2022*

Teen's Email

Teen's Cell Phone
My parish of registration is:*
Our Lady of Grace
Saint Benedict
Other

If other, 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 non-food allergy:*
No
Yes

If yes, please list the allergy/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
Eighth Teen's Name

First Name*

Middle Name

Last Name*
Eighth Teen's Date of Birth*
Eighth Teen's Information

School Attending *
Grade Level for Fall 2021-2022*

Teen's Email

Teen's Cell Phone
My parish of registration is:*
Our Lady of Grace
Saint Benedict
Other

If other, 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 non-food allergy:*
No
Yes

If yes, please list the allergy/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
Ninth Teen's Name

First Name*

Middle Name

Last Name*
Ninth Teen's Date of Birth*
Ninth Teen's Information

School Attending *
Grade Level for Fall 2021-2022*

Teen's Email

Teen's Cell Phone
My parish of registration is:*
Our Lady of Grace
Saint Benedict
Other

If other, 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 non-food allergy:*
No
Yes

If yes, please list the allergy/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
Tenth Teen's Name

First Name*

Middle Name

Last Name*
Tenth Teen's Date of Birth*
Tenth Teen's Information

School Attending *
Grade Level for Fall 2021-2022*

Teen's Email

Teen's Cell Phone
My parish of registration is:*
Our Lady of Grace
Saint Benedict
Other

If other, 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 non-food allergy:*
No
Yes

If yes, please list the allergy/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
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 Middle School YM Core Team
serve on the High School YM Core Team
help with snacks for Middle School YM
help with snacks for High School YM
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 2021-2022*

Teen's Email

Teen's Cell Phone
My parish of registration is:*
Our Lady of Grace
Saint Benedict
Other

If other, 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 non-food allergy:*
No
Yes

If yes, please list the allergy/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.


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