Youth Ministry Registration

2022-2023 Youth Ministry Registration

For the parishes in the Hamilton area, specifically: St. Aloysius, St. Julie Billiart, St. Joseph, St. Peter in Chains, & Queen of Peace.
Student Information
Student's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
School
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number to receive texts

Area CodePhone Number
Student Email
example@example.com
Emergency Information
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.*
e.g. epilepsy, diabetes, asthma
Medications taken regularly by student*
Name of Family Doctor*
Family Doctor's Phone Number*

Area CodePhone Number
Emergency Contact's Name*

First NameLast Name
Relationship to Student*
Emergency Contact Cannot be a Parent
Phone Number*

Area CodePhone Number
Alt. Phone Number*

Area CodePhone Number
Custodial Parent/Legal Guardian Information
#1 Custodial Parent/Legal Guardian Name*

First NameLast Name
Home Number*

Area CodePhone Number
Cell Number*

Area CodePhone Number
Would you like to receive text reminders from us?

YesNo
E-mail*
Address - if different from where student resides

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
#2 Custodial Parent/Legal Guardian Name

First NameLast Name
Home Number

Area CodePhone Number
Cell Number

Area CodePhone Number
E-mail
example@example.com
Address - if different from where student resides

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PERMISSION, RELEASE, AND AUTHORIZATION TO SEEK MEDICAL TREATMENT FORM (rev. 7-9-2020)

1. I, the custodial parent/legal guardian of {studentsName} (the“Child”),
1.       give permission for my Child to participate in the activity described on the Activity Information Form (the “Activity”) and release from all liability, indemnify, and hold harmless St. Aloysius (Shandon), Queen of Peace (Hamilton), St. Joseph (Hamilton), St. Julie Billiart (Hamilton), St. Peter in Chains (Hamilton), and the Archdiocese of Cincinnati (the “Archdiocese”), the Archbishop of Cincinnati (the “Archbishop”), both individually and as trustee for the Archdiocese, all parishes and schools within the Archdiocese, and all of their agents, representatives, volunteers, and employees from any and all liability, claims, judgments, damages, costs and expenses, including attorneys’ fees, arising out of any injury, illness, infectious and/or communicable disease (such as MRSA, influenza, or COVID-19), or death, (including any injury, illness, infectious and/or communicable disease, or death caused by the negligence of Parish and School, the Archbishop, the Archdiocese, any parish or school within the Archdiocese, or any of their agents, representatives, volunteers, or employees) incurred by my Child while participating in the Activity, traveling to or from the Activity, or while using the facilities and equipment of the Parish and School. I further agree not to bring or prosecute or allow to be brought or prosecuted (including, but not limited to, prosecution through subrogation) in my name, or on behalf of my Child, any claims, lawsuits, or actions against Parish and School, the Archbishop, the Archdiocese, all parishes and schools within the Archdiocese, or their agents, representatives, volunteers, and employees.

2.       I understand that my Child’s participation in the Activity is purely voluntary and is a privilege and not a right, and that my Child, and I on behalf of my Child, agree to my Child’s participation in the Activity in spite of the risks of injury, illness, infectious and/or communicable disease (such as MRSA, influenza, or COVID-19), and death. I agree that if my Child has underlying heath concerns which may place him/her at greater risk of contracting COVID-19 or that would possibly increase the severity of illness if COVID-19 is contracted, then my Child and I will consult with a health care professional before participating in the Activity.

3.       I agree to instruct my Child to cooperate with the agents of the Parish and School and/or the Archdiocese who are in charge of the Activity.

4.       I authorize the agents of the Parish and School and/or the Archdiocese who are acting as leaders of the Activity to seek medical treatment for my Child in the event of any injury, illness, or medical emergency during the Activity or related travel. I understand that the agents of Parish and School and/or the Archdiocese will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my Child.
5. Please indicate. I agree or I do not agree that Parish and School and/or the Archdiocese may use my Child's portrait or photograph for promotional purposes, website, and office functions*

I agreeI do not agree
6. Please indicate. I agree or I do not agree that Parish and School and/or the Archdiocese may use texting, social media, and/or technology to communicate with my child regarding parish/school related ministry activities.*

I agreeI do not agree
7. This Permission, Release, and Authorization is intended to be as broad and inclusive as permitted by the law of the State of Ohio, and if any portion hereof is declared invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This Permission, Release, and Authorization shall be construed in accordance with the laws of the State of Ohio, excluding, and irrespective of, any choice of law principles to the contrary.

8. Parish and School, the Archdiocese, the Archbishop and their agents, employees, and volunteers shall have no liability whatsoever in the event the Activity is cancelled due, in whole or in part, to any present or future pandemic, epidemic, widespread disease or illness, public health concern, or circumstances arising therefrom, or from actions taken by any governmental or municipal authority to prevent, avoid, or mitigate the impacts thereof.

I have carefully read and understand and accept the terms and conditions stated herein and I acknowledge and agree that this Permission, Release, and Authorization to Seek Medical Treatment shall be effective and binding upon me, my Child, and our personal representatives, estates, assigns, heirs, and next of kin. I have signed below of my own free will.
Activity Information

Please read below for descriptions of all activities
On-Going Program - Youth Ministry

Parish/School: St. Aloysius, St. Joseph, St. Julie, St. Peter in Chains, Queen of Peace

Program: Youth Ministry

Starting Date:  8-1-2022

Ending Date: 4-30-2023

Registration Fee: $0

Usual Location: St. Peter in Chains - Church and School. 451 Ridgelawn Ave. Hamilton, OH 45013

Other Locations: St. Julie Billiart - Church & Fenmont. 224 Dayton St. Hamilton, OH 45011; St. Joseph - Church & School. 171 Washington St. Hamilton, OH 45011; Queen of Peace - Church & School. 2550 Millville Ave. Hamilton, OH 45013; St. Aloysius - 3350 Chapel Rd. Shandon, OH 45063

Usual day and time: Sunday evenings, 5-8pm

Routine Activities: Prayer, formation/teaching, games, crafts, food

Group Leader: Fr. Hoffmann

Telephone No: 513-863-1040

Email: hoffmanne@stpeterinchains.org

__X___ Check here if any additional information is attached.

Calendar can be found online at: www.hamiltoncatholic.org
Name of Signing Custodial Parent/Legal Guardian*

First NameLast Name
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

2022-2023 Youth Ministry Registration

Activity Information