2020 Complete Registration Form

Child’s Name *

Date of Birth

Date

Address *

Address

Street Address Line 2

City,State

Zip Country

Age *

Sex *

Grade *

We are Registering our Child For:

Our Child will be attending Faith Formation :

Sacraments my child has already received: *

Baptism Reconciliation Eucharist/Communion Confirmation

Our Child is registering for the following Sacraments:

Baptism Reconciliation Eucharist/Communion Confirmation

Name of Church Where Baptized

City/State

Father/Guardian’s full name:

Father/Guardian’s E-mail:

Home Phone :

Cell Phone

Address

Street Address Line 2

City,State

Zip Country

Place of Work:

Place of Work Phone :

Home Phone:

Mother/Guardian’s full name:

Father/Guardian’s E-mail:

Address

Street Address Line 2

City,State

Zip Country

Cell Phone

Place of Work :

Phone :

Emergency Contact:

(if unable to reach parent/guardian in the event of an emergency)

Name & Relationship:

Phone

Insurance Carrier:

Insurance Policy Number:

Insurance is provided by which parent and/or place of employment?

Address and Phone Number of Company:

Doctor’s Name

Phone Number

MEDICATIONS: (EITHER A PHYSICIAN’S PRESCRIPTION OR A PARENT NOTE MUST ACCOMPANY ALL MEDICATIONS. PRESCRIPTION / NOTE SHOULD BE ATTACHED TO THIS FORM

My child is taking the following medication(s):

Description

Dosage

Description

Dosage

I hereby grant permission for non-prescription medications to be given, if deemed appropriate.

Drug Allergies:

Other Allergies food, plants, insects, etc:

Other known diseases, disorders, or disabilities:

If you would like your youth to participate in parish activities, please sign and return the following statement of consent and release of liability. As parent or legal guardian, you remain fully responsible for any legal responsibility which may result from any personal actions taken by your youth.

In consideration for the opportunity for my child to participate in parish activities, and fully recognizing that such an undertaking involves an element of risk, we assume all risks and hazards incidental to such participation and do hereby release, absolve, indemnify and agree to hold harmless the Diocese of Pensacola- Tallahassee and Holy Name of Jesus Parish, and their employees, agents, volunteers, and other persons acting on their behalf. Neither the Diocese of Pensacola-Tallahassee, Parish, nor said agents, employees, or volunteers, shall be held financially responsible for any injury, illness or death incurred as a direct or indirect result of this activity. We the undersigned have read this release and understand all its terms and execute it voluntarily and with full knowledge of its significance.

EMERGENCY MEDICAL TREATMENT:

In the event of an emergency, I/we hereby authorize the Diocese of Pensacola-Tallahassee, and Holy Name of Jesus Parish, through its authorized representatives, to transport my child to a hospital or other doctor’s office or medical facility for emergency medical attention. I/ We additionally authorize such representatives of the Diocese and/or Holy Name of Jesus Parish to obtain and give consent to whatever medical treatment the representative deems necessary, including the administering of anesthetic and surgery, and do hereby release the Diocese and Holy Name of Jesus Parish, and their authorized representatives from any and all claims which may arise from the above-referenced obtaining and consenting to medical treatment. I/We wish to be advised, if possible, prior to the providing of any non-emergency medical treatment by any physician or hospital.

By selecting the "I Accept" box, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept” you consent to be legally bound by this Agreement's terms and conditions. *

I accept

Signature of Parent/Guardian

Clear

This form is to be kept at the parish and renewed annually

It is the promise and commitment of the Diocese of Pensacola-Tallahassee to use pictures and videos from Diocesan and/or parish youth events in a dignified and respectful manner. I hereby authorize the Diocese of Pensacola-Tallahassee, including its parishes, schools, and institutions (hereinafter referred to as “Diocese of Pensacola-Tallahassee”) to use, prepare, reproduce, record, video tape, publish, distribute, broadcast, electronically store, and exhibit my name, image, portrait, likeness, words, and/or voice in connection with interviews, sessions, or events conducted, sponsored, or arranged by the Diocese of Pensacola-Tallahassee and its employees, volunteers, and agents. I acknowledge that any notes, photographs, motion pictures, digital images, recordings, or other media format taken of me will become the property of the Diocese of Pensacola-Tallahassee, and I specifically waive any right to compensation for the foregoing. I understand that my likeness, name, image, or voice may be used by the Diocese of Pensacola-Tallahassee without limitation for any professional purpose, now or in the future, and I consent to the same. This permission extends to any authorized print or broadcast media organization that may participate in such preparation, use, reproduction, publication, or distribution.

I release the Diocese of Pensacola-Tallahassee and its employees, volunteers, agents, and designees from liability for any violation of any personal or proprietary right I may have in connection with such use. I also hereby waive any right I may have to inspect and approve in advance the photographs, videos, sound recordings, or publications or media in which I am included. I agree to release the Diocese of Pensacola-Tallahassee and its employees, volunteers, agents and designees from any liability by virtue of the use of the photographs or video recordings, regardless of any blurring, distortion, optical illusion, or alteration which may occur when the photographs or videos are taken, printed, or displayed. A photocopy of this release shall be as valid and enforceable as the original.

By selecting the "I Accept" box, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept” you consent to be legally bound by this Agreement's terms and conditions.

I accept

I DO NOT authorize or release the Diocese of Pensacola-Tallahassee, to use, prepare, reproduce, record, video tape, publish, distribute, broadcast, electronically store, and exhibit my name, image, portrait, likeness, words, and/or voice in connection with interviews, sessions, or events conducted, sponsored, or arranged by the Diocese of Pensacola Tallahassee and its employees, volunteers, and agents.

By selecting the "I Do Not Accept" x, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Do Not Accept" you consent to be legally bound by this Agreement's terms and conditions.

I do Not Accept

Signature of Parent/Guardian

Clear

This form allows you to identify who may communicate with your minor children and by what means. Parents and guardians may choose to be included in all written or text-based communications except those that occur on an official social networking site or online community administered and maintained by the ministry, parish, or school pursuant to the terms of diocesan policy and approved by parents or guardians on this form.

Holy Name of Jesus Life Teen Communicates using :

Cell Phone number: 334-718-0652

E-Mail: aslayback@holynamechurch.org, hnjcatholicyouth@gmail.com

Instagram and Twitter : hnj_ym

You MAY NOT contact my child directly Contact with my Child is permissible via the following methods:

Phone call/voice message to this Number

SMS/Text message to this Number

E-mail at this e-mail address

By selecting the "I Accept" box, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept” you consent to be legally bound by this Agreement's terms and conditions.

I accept

Signature of Parent/Guardian

Clear

Registration fees: $20/student(max$60/family

+$15/Sacrament or RCIA Adapted for Children and Youth

**Scholarships are Available contact Aaron or Anna**

Faith Formation Registration

Annual Medical Release

Annual Media Release

Contact with Minors Form ( High School 9-12 Only)

After you click submit you will be redirected to Faith Formation Fee payment page.