*YM/CFF Registration & Release Form*

Youth Ministry Registration & Medical Release
For questions about programming for kids in 6th grade or younger, please contact sacraments@bellarminechapel.org.

For questions about programming for kids in 7th grade or older, please contact youthministry@bellarminechapel.org.
Child's Name*

First NameMiddle NameLast Name
Child's Preferred Name:
If different than teen's name field...
Child's Gender*

MaleFemaleOther
Child's School*
Child's Grade*
Child's Birthday*

MonthDayYear
Date
Child's T-Shirt Size*
Ex. Adult Small
Child's Email
example@example.com
Child's Cell
Please enter a valid phone number.
May we communicate with your child via group emails with other Youth Ministry Team members and other teens?

YesNo
May we communicate with your child via group texts and GroupMe with other Youth Ministry Team members and other teens?

YesNo
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 else we should know about your child...
Would you like to add a second child?*

YesNo

Second Child's Name*

First NameMiddle NameLast Name
Second Child's Preferred Name:
If different than teen's name field...
Second Child's Gender*

MaleFemaleOther
Second Child's School*
Second Child's Grade*
Second Child's Birthday*

MonthDayYear
Date
Second Child's T-Shirt Size*
Ex. Adult Small
Second Child's Email
example@example.com
Second Child's Cell
Please enter a valid phone number.
May we communicate with your second child via group emails with other Youth Ministry Team members and other teens?

YesNo
May we communicate with your second child via group texts and GroupMe with other Youth Ministry Team members and other teens?

YesNo
Food or Other Allergy (including dietary restrictions)
Second Child
Chronic Medical Condition (e.g., epilepsy, diabetes, etc.)
Second Child
Learning Disability
Second Child
Please let us know if there is anything else we should know about your child...
Second Child
Would you like to add a third child?*

YesNo

Third Child's Name*

First NameMiddle NameLast Name
Third Child's Preferred Name:
If different than teen's name field...
Third Child's Gender*

MaleFemaleOther
Third Child's School*
Third Child's Grade*
Third Child's Birthday*

MonthDayYear
Date
Third Child's T-Shirt Size*
Ex. Adult Small
Third Child's Email
example@example.com
Third Child's Cell
Please enter a valid phone number.
May we communicate with your third child via group emails with other Youth Ministry Team members and other teens?

YesNo
May we communicate with your third child via group texts and GroupMe with other Youth Ministry Team members and other teens?

YesNo
Food or Other Allergy (including dietary restrictions)
Third Child
Chronic Medical Condition (e.g., epilepsy, diabetes, etc.)
Third Child
Learning Disability
Third Child
Please let us know if there is anything else we should know about your child...
Third Child
Would you like to add a fourth child?*

YesNo

Fourth Child's Name*

First NameMiddle NameLast Name
Fourth Child's Preferred Name:
If different than teen's name field...
Fourth Child's Gender*

MaleFemaleOther
Fourth Child's School*
Fourth Child's Grade*
Fourth Child's Birthday*

MonthDayYear
Date
Fourth Child's T-Shirt Size*
Ex. Adult Small
Fourth Child's Email
example@example.com
Fourth Child's Cell
Please enter a valid phone number.
May we communicate with your fourth child via group emails with other Youth Ministry Team members and other teens?

YesNo
May we communicate with your fourth child via group texts and GroupMe with other Youth Ministry Team members and other teens?

YesNo
Food or Other Allergy (including dietary restrictions)
Fourth Child
Chronic Medical Condition (e.g., epilepsy, diabetes, etc.)
Fourth Child
Learning Disability
Fourth Child
Please let us know if there is anything else we should know about your child...
Fourth Child
Would you like to add a fifth child?*

YesNo

Fifth Child's Name*

First NameMiddle NameLast Name
Fifth Child's Preferred Name:
If different than teen's name field...
Fifth Child's Gender*

MaleFemaleOther
Fifth Child's School*
Fifth Child's Grade*
Fifth Child's Birthday*

MonthDayYear
Date
Fifth Child's T-Shirt Size*
Ex. Adult Small
Fifth Child's Email
example@example.com
Fifth Child's Cell
Please enter a valid phone number.
May we communicate with your fifth child via group emails with other Youth Ministry Team members and other teens?

YesNo
May we communicate with your fifth child via group texts and GroupMe with other Youth Ministry Team members and other teens?

YesNo
Food or Other Allergy (including dietary restrictions)
Fifth Child
Chronic Medical Condition (e.g., epilepsy, diabetes, etc.)
Fifth Child
Learning Disability
Fifth Child
Please let us know if there is anything else we should know about your child...
Fifth Child

Pre-K - Grade 6 Programs

(Pre-K - Grade 6 children's faith formation at Bellarmine Chapel offers the following programs.)

I would like to register my child for children's faith formation. I understand that registering means that my child can participate in the above-mentioned programs based on availability and age, that I will confirm my child's desire to participate in each of these additional programs individually, and that the details on this permission form cover all programs I desire for my child.*

Yes
Youth Ministry Programs

(Bellarmine Chapel's Youth Ministry offers the following opportunities:)

I would like to register my child for the youth ministry program at Bellarmine Chapel. I understand that registering means that my child can participate in the above-mentioned programs based on availability and age, that I will confirm my child's desire to participate in each of these programs individually, and that the details on this permission form cover all programs I desire for my child.*

Yes
* The link for payment will be on the Thank You page once you complete the registration form. But do not let any suggested fees or registration fees stop you from indicating interest. Suggested fees are not required, and scholarships for overnight events are available.

Parent/Guardian Info

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

First NameLast Name
Parent/Guardian's Email*
example@example.com
Parent/Guardian's Primary Phone*
Please enter a valid phone number.
Type of Primary Phone*

CellWorkHome
Parent/Guardian's Secondary Number
Please enter a valid phone number.
Type of Secondary Phone

CellWorkHome
Parent/Guardian's Address*

Street Address

Street Address Line 2

CityState / 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 NameLast Name
Parent/Guardian's Email (if different from other parent)
example@example.com
Parent/Guardian's Primary Phone
Please enter a valid phone number.
Type for Primary Phone

CellWorkHome
Parent/Guardian's Secondary Phone
Please enter a valid phone number.
Type for Secondary Phone

CellWorkHome
Address (if different from other parent/guardian)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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

First NameLast Name
Emergency Contacts Relation to Teen*
Emergency Contact's Cell Number*
Please enter a valid phone number.
Family Doctor / Practice Name*

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 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 agreeI 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 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.
By selecting 'I AGREE' above and signing your name here, this counts as a legal signature and acknowledges agreement to the aforementioned terms.
Do you agree with the Archdiocesan Policy for Youth Activities?*

I agree

By signing and dating below, I affirm that I have reviewed and updated the information above for my child for the 2022-2023 school year.
2022 - 2023 Signature

Clear
Date Signed

MonthDayYear
Date

By signing and dating below, I affirm that I have reviewed and updated the information above for my child, and that this permission form is effective from the date I sign this form until the end of summer 2024.
2023 - 2024 Signature*

Clear
Date Signed*

MonthDayYear
Date

By signing and dating below, I affirm that I have reviewed and updated the information above for my child, and that this permission form is effective from the date I sign this form until the end of summer 2025.
2024 - 2025 Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Parish	Bellarmine Chapel
Program	GIFT (Growing in Faith Together)
Starting Date	September
Ending Date	April
Suggested Fee	$100 first child, $80 additional children*
Usual Location	Xavier University Campus - Hailstones Hall
Usual Day/Time	10:15-11:15 am
Routine Activities	Sacramental Preparation, Prayer, Crafts
Group Leader Phone	513-745-3377
Other Information

Parish	Bellarmine Chapel
Program	First Communion
Starting Date	February
Ending Date	May
Suggested Fee	$40 suggested donation
Usual Location	Xavier University Campus - Hailstones Hall
Usual Day/Time	Sundays 10:15-11:15 a.m.
Routine Activities	Sacramental preparation for parents and children
Group Leader Phone	513-745-3377
Other Information

Parish	Bellarmine Chapel
Program	Reconciliation
Starting Date	November
Ending Date	December
Registration Fee	$30
Usual Location	Hailstones Hall
Usual Day/Time	Sundays 10:15-11:15 am
Routine Activities	Sacramental preparation for parents and children
Group Leader Phone	513-745-3377
Other Information

Parish	Bellarmine Chapel
Program	Daring Disciples Camp
Starting Date	July 24, 2023
Ending Date	July 28, 2023
Registration Fee	$35 first child, $25 additional children*
Usual Location	Xavier University Campus - Conaton Learning Center
Usual Day/Time	Monday - Friday from 9:00 a.m. to Noon
Routine Activities	Activities, Crafts, Music, Prayer
Group Leader Phone	513-745-3377
Other Information

Parish	Bellarmine Chapel
Program	6th Grade Preview
Starting Date	March
Ending Date	May
Registration Fee	A $20 donation to attend the junior high retreat
Usual Location	Xavier University Campus
Usual Day/Time	Various
Routine Activities	Activities, Crafts, Music, Prayer
Group Leader Phone	513-268-7105
Other Information	Toward the end of the school year, 6th graders will be invited to various youth group events to prepare them for the upcoming year. This may include youth group gatherings, fun nights, service days, and even the junior high retreat!

Parish	Bellarmine Chapel
Program	Confirmation Preparation
Starting Date	September
Ending Date	May
Suggested Fee	$50 suggested donation for the retreat
Usual Location	Xavier University Campus
Usual Day/Time	TBD
Routine Activities	Catechesis, activities, small groups
Group Leader Phone
Other Information	All Confirmation candidates are expected to participate in Bellarmine's Youth Group weekly on Sundays 4:30 - 6:45. Sessions include dinner and the option to attend the 7 pm Mass together. Please sign up for both Confirmation and Youth Group. There will also be a Confirmation retreat that should be attended by all Confirmation candidates. The Sacrament of Confirmation will be celebrated on May 18, 2025, at 10:30 am at St. Xavier Church.

Parish	Bellarmine Chapel
Program	High School Retreat
Starting Date	Saturday February 22, 2025
Ending Date	Sunday February 23, 2025
Suggested Fee	$50 suggested donation
Usual Location	Higher Ground, Indiana
Usual Day/Time	Saturday Morning through Sunday Afternoon
Routine Activities	Prayer, Activities, Discussion, Personal Reflection
Group Leader Phone
Other Information	Expected for all Confirmation candidates. Parents drop off teens at retreat center (https://hgcrc.org/)

Youth Ministry Registration & Medical Release

Pre-K - Grade 6 Programs

Youth Ministry Programs

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.