GNAC Senior Youth Ministry Registration Form

Student Information:

Name ________________________________________     Sex      M         F         Grade ____________________

Birthday ______/______/______      Age ______     E-Mail ____________________________________________

High School ___________________________  Home Phone # _____________ Cell Phone #_________________

Alternative Forms of Communication:              Facebook Account?  Y / N         Texting Capabilities?  Y / N

Address ___________________________________ City ________________________ Zip_______________

What Parish are you (and/or your family) a registered member?  (circle one)

St. Agnes               St. Elizabeth Ann Seton                    Immaculate Conception                   Other ________________________

Parental Information:

Mother’s First Name _______________________ Last Name (if different from child) _________________

Mother’s Religion __________________________  Mother’s Cell Phone # _________________________

Father’s First Name ________________________ Last Name (if different from child) _________________

Father’s Religion ___________________________  Father’s Cell Phone # __________________________

Mother’s E-mail ___________________________ Father’s E-mail _________________________________

(If applicable, please enter one or both parents’ e-mail/s to receive SYM mailings w/ weekly meeting & event info.)

Student Medical Information:

Disabilities, Allergies, or Health Issues: ________________________________________________________

Any other issues you think that we need to be aware of (custody, special schedules, etc.): ______________

__________________________________________________________________________________________

In case of emergency, call:

Name _____________________________  Phone # _________________  Relationship _________________

*Permission to publish a photograph of my child on the GNAC Youth website:  We have a website for the Greater Norwin Area Catholic Youth Ministries online at www.gnacyouth.org.  Photos only (no names) will be included on this website, please indicate below (w/ your initials) if we have your permission for your child to appear in a photo that may be posted:

YES, you have my permission for my child’s face to appear in any photo used on the website.  _____________

NO, I do not give permission for my child’s face to appear in any photo used on the website.  ______________

*Website also includes online music, Catholic links, Catholic podcasts, monthly calendars of events, permission slips, etc. 

Medical Release Purpose

To Whom it may concern,

          As a parent and/or guardian. I do hereby authorize the treatment by a qualified and licensed medical doctor of the following minor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed.  This authority is granted only after a reasonable effort has been made to reach me.

I understand that neither Greater Norwin Area Catholic Senior Youth Ministry nor any of its agents are responsible for any injury sustained by my child. I accept responsibility for any medical expenses as a result of any such injury sustained.

(Parent or Guardian Signature) __________________________________________________________________________________

(phone number)_______________________________________________    (date)_________________________________________

This release is intended for the duration of the ’11-’12 school year.  This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.

Signed ___________________________________________________        ____________________________

                                        (father, mother, legal guardian)                                                                            (date)

__________________________________________________________________________________________________

(address)                                                                      (city)                                                          (state)                                 (zip)

________________________________________                                    ________________________________________

               (home phone #)                                                                                                          (work phone #)

Family Physician____________________________________________            (Phone #)___________________________

Specific medical allergies, chronic illnesses or other condition:

__________________________________________________________________________________________

Another person to contact in case of emergency:

___________________________________________                                   _____________________________ 

                                             (name)                                                                                                                     (phone)