Middle School Youth Ministry Registration (22-23)

Middle School Youth Ministry Registration (2022-2023)

Please complete the registration in full. Information submitted will be treated as strictly confidential!
Registration Fee: The registration fee is $50 per child ($90 for two children, $140 for three or more children) to help cover the cost of resources.

At the bottom of this form you can pay online use square. Square is a secure app that allows St. Pius X to take payments online. If you would still prefer to pay with cash or check, made payable to "St. Pius X Youth Ministry", you can drop it off, during normal business hours or mail it to the parish office. (23 Crumitie Rd, Loudonville, NY 12211)
How many students would you like to register for Middle School Youth Ministry?*

123
Youth Information

Please fill out all required fields
Student 1
Youth Name:*

First NameLast Name
Date of birth:*
mm/dd/yyyy
School*
Class of (High School Graduation Year):*
2024, 2025, 2026, etc...
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Youth Cell Phone:

Area CodePhone Number
Youth Email:*
example@example.com
Parish (If not St. Pius X)
Student 2
Youth Name:*

First NameLast Name
Date of birth:*
mm/dd/yyyy
School*
Class of (High School Graduation Year):*
2024, 2025, 2026, etc...
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Youth Cell Phone:

Area CodePhone Number
Youth Email:*
example@example.com
Parish (If not St. Pius X)
Student 3
Youth Name:*

First NameLast Name
Date of birth:*
mm/dd/yyyy
School*
Class of (High School Graduation Year):*
2024, 2025, 2026, etc...
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Youth Cell Phone:

Area CodePhone Number
Youth Email:*
Parish (If not St. Pius X)
Parent/Guardian Information

Please fill out all required fields
Parent/Guardian 1 Name:*

First NameLast Name
Parent/Guardian 1 Email:*
example@example.com
Parent/Guardian 1 Phone Number:*

Area CodePhone Number
Parent/Guardian 2 Name

First NameLast Name
Parent/Guardian 2 Email
example@example.com
Parent/Guardian 2 Phone Number

Area CodePhone Number
Small Group Information
In the spirit of forming discipleship among our core team and youth, a large portion of our ministry nights are spent gathered in small groups. We will try to maintain the same small groups throughout the year. Our core team will gather in prayer and entrust the forming of these small groups to the Holy Spirit. We ask that you please help us with this process, and join us in prayer.
Please list 1-2 names of other youth in our program (of the same grade) you'd like to be in a small group with. While we cannot promise small group matches, we can promise our Core Team will be praying for an outpouring of the Holy Spirit in forming these small groups!*

Open to be anywhere, and eager to meet new friends in Christ!
Youth Medical Information

Please fill out all required fields
Allergies:*

Yes, please fill out box belowN/A, skip to next question
Allergies:
Dietary Restrictions:*

Yes, please fill out box belowN/A, skip to next question
Dietary Restrictions:
Does youth participant take any medication?:*

Yes, please fill out box belowN/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 NameLast Name
Emergency Contact Phone Number:*

Area CodePhone Number
Emergency Contact Relation to Youth:*
Consent

Please fill out all required fields
MEDICAL CONSENT

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
IMAGE & LIKENESS CONSENT - (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 agreeNo
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
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
Payment

Square is a secure app that allows St. Pius X to take payments online. Please enter your information below. If you would still prefer to pay with cash or check, made payable to "St. Pius X Youth Ministry", you drop it off, during normal business hours or mail it to the parish office. (23 Crumitie Rd, Loudonville, NY 12211)
I plan to pay the MSYM Fee by...*

CashCheckCard

If you choose to pay by check, please make all checks payable to St. Pius X Church.

All payments are due by the first time a student attends a Middle School Youth Ministry evening

Registration Fees:

1 Student: $50

2 Students: $95

3+ Students: $140
Have any questions, comments, or concerns?
Acknowledgement
Parent/Guardian Acknowledgement:*

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

Clear
Youth Participant Acknowledgment:*

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

Clear
Should be Empty:

Middle School Youth Ministry Registration (2022-2023)

Youth Information

Student 1

Student 2

Student 3

Parent/Guardian Information

Small Group Information

Youth Medical Information

Consent

Payment

Credit Card

Acknowledgement