Youth Ministry Registration 25-26

If you have any questions, please reach out to Colette at [email protected]

Child Information:

Child's First Name*

Answer required for "Child's First Name"

Child's Last Name*

Answer required for "Child's Last Name"

Child's Birthdate*

Answer required for "Child's Birthdate"

Which program are you registering this child for?*

Answer required for "Which program are you registering this child for?"

Middle School

High School

Grade in September 2025*

Answer required for "Grade in September 2025"

Name of School*

Answer required for "Name of School"

Parent Information:

Parent Name*

First and Last Name

Answer required for "Parent Name"

Parent Email*

Answer required for "Parent Email"

Parent Phone Number*

Number Required

Home Address*

Answer required for "Home Address"

City*

Answer required for "City"

Zip Code*

Answer required for "Zip Code"

Parent occupation*

Answer required for "Parent occupation"

Are you willing to help out with our YM program? (Provide food, chaperone trips, give talks, facilitate small groups etc.)*

Answer required for "Are you willing to help out with our YM program? (Provide food, chaperone trips, give talks, facilitate small groups etc.)"

Emergency Contact Information:

Name of Emergency Contact (other than parent) *

Answer required for "Name of Emergency Contact (other than parent) "

Relationship *

Answer required for "Relationship "

Cell Number *

Answer required for "Cell Number "

Medical History of Child

Please select yes or no. If you respond yes, please explain in box below.

Please note: Your child will not be able to participate in our Youth Ministry program if he/she has any of the following symptoms:

- Fever or Chills, Shortness of breath or difficulty breathing, Vomiting, Diarrhea, Fatigue, Coughing, Body Aches, Headache, Sore Throat

Does your child have any other significant health problems? Is there anything we should know about your child that might help us with any situation that might present itself during our activities? (If yes, please describe).

Answer required for "Does your child have any other significant health problems? Is there anything we should know about your child that might help us with any situation that might present itself during our activities? (If yes, please describe)."

Special Needs/Notes

Answer required for "Special Needs/Notes "

Please explain any "Yes" answers from above:

Answer required for "Please explain any \"Yes\" answers from above:"

Parental Permission and Liability Release*

Answer required for "Parental Permission and Liability Release"

As parent/legal guardian of the participant names above, I give my permission to participate fully Youth Ministry Activities from September 21st to June 7th, 2026 I agree to indemnify and hereby release the Most Reverend Michael F. Burbidge Bishop of the Catholic Diocese of Arlington and his successors in office, as well as the Catholic Diocese of Arlington and all Diocesan clergy, employees, volunteers, and participating parishes and schools from any and all liability, claims, demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned of the participant resulting from said participant’s involvement in the above mentioned event (including transportation to and from the event). Furthermore, I on behalf of the participant hereby assume all risk of personal injury, sickness, death, damage, and expenses resulting from said participant’s involvement in the above described event.

Medical Acknowlegdement*

Answer required for "Medical Acknowlegdement"

I request that in my absence the above-named minors be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor. I assume full responsibility for all costs of such treatment. Further, should it be necessary for the participant to return home due to medical, disciplinary, or other reasons, I do hereby assume responsibility for the participant’s transportation home and any costs related thereto.

Photo and Media Release*

Answer required for "Photo and Media Release"

I authorize the Arlington Diocese and Holy Family Catholic Church to use my child´s picture or video for educational and/or marketing purposes. Should the need arise; I give permission for my child/children to receive emergency medical care while participating in Holy Family Church Youth Ministry program.

Signature*

Signature Required

Do NOT leave anything blank on this form. All items are required to submit the form.

Please fix the highlighted areas below before submitting.

Youth Ministry Registration 25-26