High School Youth Ministry Registration (20-21)

This registration form is for all High School Youth (grades 9-12) that would like to participate in our St. Pius X High School Youth Ministry program who have already been Confirmed or are not enrolled in our Confirmation Program.

If you are currently registered for our Confirmation Program, you do not need to fill out this form.

Youth Name: *

First Name Last Name

Class of (High School Graduation Year): *

2024, 2025, 2026, etc...

Date of birth: *

mm/dd/yyyy

Please submit a picture with your registration. In the event of needing to meet entirely virtual, this will help our team put a face with a name.

Youth Photo (Photo of youth registrant only, please no group photos)

Which program are you registering for? We ask that your family commit to either in person or virtual HSYM. This can be changed January 2021 *

In person High School Youth Ministry (Wednesdays, 6:30-8:15pm) Remote / Virtual High School Youth Ministry (Wednesdays 7:15-8:15pm)

Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Youth Cell Phone:

Area Code Phone Number

Youth Email: *

Parish (If not St. Pius X)

Parent/Guardian 1 Name: *

First Name Last Name

Parent/Guardian 1 Phone Number: *

Area Code Phone Number

Parent/Guardian 1 Email: *

example@example.com

Parent/Guardian 2 Email

First Name Last Name

Parent/Guardian 2 Phone Number

Area Code Phone Number

Parent/Guardian 2 Email

example@example.com

Youth Medical Information

Due to COVID-19 safety regulations, prior to every in-person youth ministry session, parents/guardians must complete a health screening for each child/youth attending. A digital and printable version of this health screening form can be found on the youth ministry pages of our parish website. *

I acknowledge and agree to complete a health screening prior to every in-person session

Allergies: *

Yes, please fill out box below N/A, skip to next question

Allergies:

Dietary Restrictions: *

Yes, please fill out box below N/A, skip to next question

Dietary Restrictions:

Does youth participant take any medication?: *

Yes, please fill out box below N/A, skip to next question

Please list medication name and dosage:

Medical Conditions & Disabilities (Is there anything we should be aware of? Do you require special assistance during the event/program)

Insurance Provider:

Policy Number:

Primary Policy Holder:

In case of an emergency, please contact: *

First Name Last Name

Emergency Contact Phone Number: *

Area Code Phone Number

Emergency Contact Relation to Youth: *

PARENT/GUARDIAN

I understand that my youth will be responsible for his/her own administration of medication, "self-directed." I understand that the volunteer leaders of the Roman Catholic Diocese of Albany and St. Pius X Church are not licensed health care professionals and take no responsibility to supervise the administration of required medications, which as stated above is to be "self-directed" by my youth.

In consideration of the acceptance of this self-directed permission, I hereby, for myself, my heirs, executors, administrators and assigns, waive and release any and all claims for damages I may have against the Roman Catholic Diocese of Albany and St. Pius X Church their representatives, employees, successors and assigns, arising out of any and all injured sustained.

*

I Agree

PARENT/GUARDIAN - Youth Photo/Video Release

I hereby authorize and give my consent for the taking of pictures (moving or still) and for their reproduction or posting on social media (facebook/twitter/periscope/instagram/website) for:
1. teaching purposes 2. news release 3. publication 4. community awareness 5. pubilicity and promotion of conference/activities
I understand that I and my child are not entitled to any compensation or rights in the materials and I release St. Pius X Church and the Roman Catholic Diocese of Albany from any liability for the use of my child's image for the above stated purpose.

Photo/Video Release Permission *

I agree No

PARENT/GUARDIAN and YOUTH read over:

As a participant of the St. Pius X event/program, I understand and agree to the rules and regulations as determined by the Roman Catholic Diocese of Albany, and St. Pius X Church. I also understand and agree that I will notify my parents or guardian at the time of any infractions requiring my dismissal from the event and that I will be sent home at my own and/or my parent’s or guardian’s expense.

*

I Agree

YOUTH CODE OF CONDUCT

This Code of Conduct is for use with youth under 18 years who serve as volunteers, participants or are in work placement in parishes or schools. Young people under 18 are not required to attend VIRTUS training and apply for a background check as a condition for their ministry or work. Adults responsible for the supervision of young people in ministry or work situations need to review this document with the young person and clarify/explain any part that may not be understood by the young person. This can be done in a group or individual meeting. This form is to be read and filled out by the young person, the parent/guardian, and the supervisor. The form will be kept in the parish or school. I promise to follow the rules and guidelines in this Code of Conduct. I understand that any action inconsistent with or failure to take action mandated by this Code of Conduct may result in my removal from my volunteer or work assignment.

As a youth participant, volunteer or worker I will:

• Safeguard children and other youth entrusted to my care at all times.
• Treat everyone with respect, loyalty, patience, integrity, courtesy and dignity.
• Take care to be positive, supportive, and caring in my speaking, writing, and interacting with children and youth.
• Avoid situations in ministry or work where I am alone with any child.
• Use positive reinforcement rather than criticism or comparison when working with children/youth.
• Cooperate fully in any investigation of abuse of children/youth. Report suspected abuse to my supervisor, or if it involves my supervisor, report it to the pastor/parish life director.
• Be aware that children/young people can easily become infatuated with a youth leader or an adult. If I sense this is happening, I will not encourage it. I will make my supervisor aware of it so that he/she can resolve the matter, including reassigning me to other activities.
• Maintain appropriate physical and emotional boundaries with children/youth.
• Dress modestly and appropriately and not wear any clothing with offensive messages or pictures while exercising my ministry or working.

As a youth participant, volunteer or worker I will not:

• Endorse, during my ministry, any view contrary to the teachings of the Catholic Church.
• Commit an illegal or immoral act.
• Smoke or use tobacco products in the presence of minors.
• Use, possess or be under the influence of alcohol or illegal drugs at anytime while at work or volunteering.
• Verbally threaten or physically abuse anyone.
• Use profanity in the presence of any child, youth or adult.
• Use discipline that frightens or humiliates a child/youth.
• Touch a child/youth in a sexual, overly affectionate or other inappropriate manner.
• Place myself in a situation where my interactions with a child/youth would not be visible to others.
• Accept gifts from or give gifts to children/youth in my care without approval from my supervisor.
• Tolerate inappropriate or bullying behavior by a child/youth towards another child/youth.
• Communicate with minors in my charge about matters unrelated to my responsibilities within ministry.

By checking the box below, I agree that, along with my parent/guardian(s) I, have read and understand the Roman Catholic Diocese of Albany Code of Conduct for Youth Workers and Volunteers and will honor them while at work or as a volunteer. Both my parents and I understand and agree that the parent/guardian will be notified at the time of any infraction requiring dismissal from work or volunteer assignment at the parish or school where the young person is working or ministering.

*

I Agree

I CERTIFY THAT THE FACTS CONTAINED IN THIS REGISTRATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

I HEREBY GRANT PERMISSION/CONSENT FOR THE ABOVE YOUTH TO PARTICIPATE IN THE EVENT STATED ABOVE WITH THE ROMAN CATHOLIC DIOCESE OF ALBANY, AND ST. PIUS X CHURCH

I AUTHORIZE THE VOLUNTEERS, REPRESENTATIVES, AND CHAPERONE OF THE ROMAN CATHOLIC DIOCESE OF ALBANY, AND ST. PIUS X CHURCH TO OBTAIN MEDICAL/EMERGENCY MEDICAL TREATMENT, SHOULD IT BE NECESSARY, DURING MY CHILD'S ATTENDANCE AND PARTICIPATION IN ABOVE EVENT. I UNDERSTAND THAT I WILL BE NOTIFIED IMMEDIATELY SHOULD IT BECOME NECESSARY TO OBTAIN MEDICAL/EMERGENCY TREATMENT. I RELIEVE THE ROMAN CATHOLIC DIOCESE OF ALBANY AND ST. PIUS X ALL RESPONSIBILITY AND CONSEQUENCES THAT MAY ARISE AS A RESULT OF THIS TREATMENT. I WILL NOT HOLD THE ROMAN CATHOLIC DIOCESE OF ALBANY, AND ST. PIUS X CHURCH LIABLE IN THE EVENT OF INJURY. FURTHER, I AGREE TO ACCEPT ANY AND ALL FINANCIAL RESPONSIBILITY AS A RESULT OF THE SCHEDULING MEDICAL TREATMENT.

I FULLY UNDERSTAND WHAT IS INVOLVED IN THIS EVENT AND I UNDERSTAND THAT I HAVE THE OPPORTUNITY TO CALL YOUTH MINISTER OF MY YOUTH'S GROUP.

*

I Agree

Have any questions, comments, or concerns?

Parent/Guardian Consent: *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

Youth Participant Consent: *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

High School Youth Ministry Registration (2020-2021)