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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. 


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PARISH NAME: The Partner Parishes of Our Lady of Grace and Saint Benedict

PARISH ADDRESS: 1011 Mount Pleasant Road Greensburg PA 15601 / 260 Bruno 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 separate permission form.  

TRANSPORTATION: NONE

COST: NONE (extra events, with separate permission forms, may incur a fee)

COVID Protocols: The Youth Ministry will follow all COVID protocols of the Diocese of Greensburg.  Masking during on-site youth ministry events is optional and the decision of the parents/guardians of the teen, unless a mandate should be directed by the Diocese. 

ON-SITE EVENT CONSENT
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.

VIRTUAL GATHERING CONSENT IF NEEDED 

We, the parents/guardians do hereby give our permission for him/her to attend VIRTUAL YOUTH MINISTRY SESSIONS for the 2022-2023 Catechetical Year.

INTRODUCTION

This Policy, and any subsequent policies, is designed to make virtual learning available for parish faith formation and youth ministry communities and promote the responsible and safe use of resources. Cooperation and adherence to this Policy is a condition of access to the aforementioned resources. Violation of this Acceptable Use Policy will result in disciplinary action, which may include removal of access or other applicable consequences, and may have significant legal and/or financial consequences.

ACCEPTABLE AND UNACCEPTABLE USE

The Internet offers the capability for students and catechists to access and share information on a global scale. The scholarly use of the Internet can provide our students and catechists with a world-wide, diverse array of resources.

Users will observe the following practices and precautions during virtual learning and online live classroom meetings to help ensure that the use of technology is a safe, productive, and educationally rewarding experience:

Students are expected to be on time, appropriately dressed and seated in an appropriate manner for learning.

Students should be respectful at all times of catechist and others in the virtual classroom.

Students screen must use correct names and appropriate backgrounds.

Students remain active, engaged, and visible at all times, face to face.

Students remain on mute and only unmute when called upon.

Students with questions use “raise hand button.”

Student and families may not share the link to the “virtual” classroom with others.

Users agree to the following practices to ensure personal safety and well-being:

While during virtual faith formation, the user agrees never to transmit personally identifiable information (name, age, gender, social security number, address, phone number, credit/debit card information and the like) of himself or herself as well as that of any other person.

The student agrees never to arrange for a face-to-face meeting with any person at any time during virtual faith formation. Student users will not agree to meet with someone they have met online without their parents' full approval and participation.

The student agrees to notify faith formation personnel immediately if he or she is asked for personal information, views inappropriate materials, or in any other way feels violated, harassed, uncomfortable, or accosted through the use of the parish technology resources.

Users agree to the following statements regarding illegal/unauthorized activities and system security:

The user agrees to access only the Internet and network resources, software and/or hardware provided expressly by the parish for educational purposes.

The user agrees to follow the procedures and best practices recommended by parish personnel or system administrator. These procedures and practices may address respect for the resource limits of the parish, personal safety issues, and/or access to appropriate materials.

The user agrees never to use or respond to inappropriate, obscene, profane, rude, inflammatory, threatening, or disrespectful language.

The user agrees never to post false information or engage in personal, prejudicial, or discriminatory attacks.

The user agrees to at no time unlawfully harass, intimidate, haze, or bully (which includes cyberbully) another person through the use of any parish online resources.

The user agrees never to access, possess, transmit, retransmit or respond to any information containing sexually oriented material.

The user agrees never to use parish technology resources to engage in any illegal, criminal activity or any conduct which is morally inappropriate and/or violates Catholic teachings. The parish will cooperate fully with local, state, or federal officials in any investigation related to any illegal activities.

The user agrees never to plagiarize. Plagiarism is defined as taking the idea or writing of others and presenting them as one's own.

The user agrees to respect the right of intellectual property of other people and to respect all copyright laws. Students agree that if they are unsure whether copyright law is being respected, they will bring this question immediately to the attention of a catechist.

Liability:

The Diocese of Greensburg, its parishes, its employees, and its faith formation volunteers will not be held responsible for the actions of a user who is in violation of any of the terms of this policy. This responsibility is extended to, but not limited to: loss or unavailability of data or interruptions of service, violations of copyright restrictions, the accuracy or quality of information obtained through the parishes system, or any liability, damages, or financial obligations arising through the unauthorized use of the parish and/or personal technology resources.

Warranties:

The Diocese of Greensburg, its parishes, its employees, and its faith formation volunteers makes no warranties of any kind, whether expressed or implied, for the service we are providing.

The Diocese and Parish will not be responsible for the accuracy, quality, or usefulness of information obtained through network connections.

The Diocese and Parish will not be responsible for any information that may be lost, damaged, or unavailable due to technical or other difficulties.

The Diocese and Parish will limit individual user network storage/disk space specific to the needs/responsibilities of the user.

The Diocese and Parish will not be responsible for the contents of any web site bearing their name(s) unless the web page has been authorized by the administration of the Diocese.

The parish administration reserves the right to establish rules and regulations regarding the use of the system.

PARENT/GUARDIAN PERMISSION TO ACTIVATE USER PRIVILEGES

I certify that I have read the terms and conditions in the Diocese of Greensburg Faith Formation Acceptable Use Policy and discussed them with my child. I understand that access to the Internet, technology and communications systems are designed for educational, security, and safety purposes and that my child has agreed to abide by the Diocese of Greensburg usage rules. I understand that my child has responsibility for his or her actions in regard to the use of technology resources and recognize my responsibility for governing and guiding access during virtual learning. I also understand that the consequences, as stated in the policy, for inappropriate actions or conduct. I recognize that it is impossible for the Diocese and Parish to restrict access to all controversial materials and I will not hold the Diocese and Parish, Ddiocese or their personnel responsible for material acquired or viewed through technology resources. I hereby give my permission to activate any faith formation technology privileges for my child.

PARENT/GUARDIAN PERMISSION FOR RECORDING OF VIRTUAL CLASSROOM MEETINGS

I understand that live virtual meetings that take place without parents present will be recorded for safe environment purposes. These recordings will not be published or shared with anyone except with proper personnel in the instance that safe environment is called into question.


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: December 8, 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 2022-2023*

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 2022-2023*

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 2022-2023*

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 2022-2023*

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 2022-2023*

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 2022-2023*

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 2022-2023*

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 2022-2023*

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 2022-2023*

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 2022-2023*

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*
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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also 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 2022-2023*

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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