BYG/byg Registration & Release Form

BYG/byg Registration & Release Form

Updated 2/13/2022 by Michelle Blevins, Director of Youth Ministry
Parents, please complete and submit this form so your teens may participate in our weekly on campus BYG/byg gatherings on Sundays from 4:30 - 630 and other BYG/byg events such as Fun Fridays, Service Saturdays, retreats, and immersion experiences as per the archdiodesan policy. Weekly gatherings often include activities such as prayer, discussion, icebreakers, and more.
Teen's Name *

First Name Middle Name Last Name
Preferred Name:
If different than teen's name field...
Birthday *

Month Day Year
Date
Gender *

Male Female Other
School *
Grade *
Enter Grade Number
Teen's Email
example@example.com
Teen's Cell
Please enter a valid phone number.
Food or Other Allergy (including dietary restrictions)
Chronic Medical Condition (e.g., epilepsy, diabetes, etc.)
Learning Disability
Please let us know if there is anything about your child that we should be aware of and that will help us teach them more effectively. Be sure to include any fears or concerns you child has:
Would you like to add another child?

Yes No

2nd Teen's Information
Teen's Name

First Name Middle Name Last Name
Preferred Name:
If different than teen's name field...
Birthday

Month Day Year
Date
Gender

Male Female Other
School
Grade
Enter Grade Number
Teen's Email
example@example.com
Teen's Cell
Please enter a valid phone number.
Food or Other Allergy (including dietary restrictions)
Chronic Medical Condition (e.g., epilepsy, diabetes, etc.)
Learning Disability
Please let us know if there is anything about your child that we should be aware of and that will help us teach them more effectively. Be sure to include any fears or concerns you child has:
Would you like to add another child?

Yes No

3rd Teen's Info
Teen's Name

First Name Middle Name Last Name
Preferred Name:
If different than teen's name field...
Birthday

Month Day Year
Date
Gender

Male Female Other
School
Grade
Enter Grade Number
Teen's Email
example@example.com
Teen's Cell
Please enter a valid phone number.
Food or Other Allergy (including dietary restrictions)
Chronic Medical Condition (e.g., epilepsy, diabetes, etc.)
Learning Disabilities
Please let us know if there is anything about your child that we should be aware of and that will help us teach them more effectively. Be sure to include any fears or concerns you child has:

Parent/Guardian Info

There will be an option to add an additional parent at the bottom of the page.
Parent/Guardian's Name *

First Name Last Name
Parent/Guardian's Email *
example@example.com
Parent/Guardian's Cell *
Please enter a valid phone number.
Parent/Guardian's Work Number
Please enter a valid phone number.
Parent/Guardian's *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Would you like to add information for an additional parent or guardian *

Additional Parent/Guardian Info
Parent/Guardian's Name *

First Name Last Name
Parent/Guardian's Email (if different from other parent)
example@example.com
Parent/Guardian's Cell *
Please enter a valid phone number.
Parent/Guardian's Work Number
Please enter a valid phone number.
Address (if different from other parent/guardian)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Emergency Info
Emergency Contact Name (other than parent/guardian) *

First Name Last Name
Emergency Contacts Relation to Teen *
Emergency Contact's Cell Number *
Please enter a valid phone number.
Family Doctor / Practice Name (if different by student, please show student and their doctor / association *
Insurance Information
What parent/guardian is this insurance under? *
Medical Insurance Company *
Group # *
Plan # *
I.D. # *

Archdiocesan Policy for Youth Activities

This waiver is a form required by the Archdiocese of Cincinnati. It will be required for all Bellarmine Youth Ministry Events
1. I, the custodial parent/legal guardian of __________________________________________ (the “Child”), 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. Robert Bellarmine Parish (aka Bellarmine Chapel) (“Parish and School”), 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 Parish and School and/or the Archdiocese who are in charge of the Activity.
4. I authorize the agents of 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.
Child's Portrait or Photograph... *

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

I agree I 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.
Liability in the event an activity is cancelled...

I agree I do not agree
By selecting 'I AGREE' above and signing your name here, this counts as a legal signature and acknowledges agreement to the aforementioned terms.

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.
Do you agree with the Archdiocesan Policy for Youth Activities? *

I agree
If you do NOT agree, please list your stipulations:
Signature

Clear
Date Signed *

Month Day Year
Date
Should be Empty:

BYG/byg Registration & Release Form

2nd Teen's Information

3rd Teen's Info

Parent/Guardian Info

Additional Parent/Guardian Info

Emergency Info

Insurance Information

Archdiocesan Policy for Youth Activities

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

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.

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

By selecting 'I AGREE' above and signing your name here, this counts as a legal signature and acknowledges agreement to the aforementioned terms.