Youth Ministry Registration Form

Youth Ministry Registration (1/3)
Student Name*

First NameLast Name
MaleFemale
Birthday*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Grade in Fall:
Student Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Youth Ministry Registration (2/3)
- Mother's Name*
  
  First NameLast Name
- Mother's Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Mother's Email
  example@example.com
- Father's Name*
  
  First NameLast Name
- Father's Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Father's Email
  example@example.com
- Emergency Contact*
- PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER (3/3)
- I,   First Name   Last Name , grant permission for my child,   First Name   Last Name   , to participate in this parish event. This activity will take place under the guidance and direction of parish employees and / or volunteers from St. Timothy Catholic Parish
  
  A brief description of the activity follows:
  Type of Event:  St Timothy Youth Ministry
  Date of Event:  2024-2025
  Destination of Event: St Timothy
  Individual in Charge: Justin Mora
  Estimated Time of Departure and Return:
  Mode of Transportation to and From Event:
  
  As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above-named Child. I agree on behalf of myself, my Child named herein, as well as our respective heirs, successors, and assigns, to hold harmless and defend St. Timothy Catholic Parish, and The Roman Catholic Bishop of San Diego, a corporation sole (“Diocese of San Diego”), and their respective clergy, officers, directors, employees, agents, volunteers, chaperones and representatives associated with the event, from any claim arising from or in connection with any illness or injury (including death) suffered by the above-named Child related to the above-referenced event, including the cost of medical treatment in connection therewith, and I agree to compensate the Parish, the Diocese of San Diego, and their respective clergy, officers, directors, employees, agents, volunteers, chaperones and representatives associated with the event for reasonable attorney fees and expenses which may incur in an action brought against them as a result of such injury or damage, unless such claim arises from the negligence or willful misconduct of the Parish or Diocese of San Diego.
       Signature    Date
  
  
  MEDICAL MATTERS
  I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
  
  *Of the following statements pertaining to medical matters, sign only those in accordance with your wishes*
  
  EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I will to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:
  First Name
  Relationship
       Area Code   Phone Number
  Family Doctor
        Area Code   Phone Number
  Family Health Plan Carrier
  Policy Number
  
  Signature   Date
  
  OTHER MEDICAL TREATMENT: In the event it comes to the attention of the parish, the Diocese of San Diego, its officers, directors, agents, volunteers, chaperones, and representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever or diarrhea, I want to be contacted.
  Signature   Date
  
  MEDICATIONS: My child is taking medication at present. My child will bring all medications necessary, and such medications will be well labeled. Names of medications and concise instructions for seeing that child takes such medications, including dosage and frequency of dosage is as follows:
  Type Here
  
      Signature   Date
  
  MEDICATIONS: CHOOSE ONE OF THE BELOW LISTINGS: (A OR B)
  
  A) No medication of any type whether prescription or non-prescription may be administered to my child unless the situation is life-threatening and emergency treatment is required.
  
  Signature   Date
  
  B)   I hereby grant permission for nonprescription medication (such as child-safe pain relievers, throat lozenges, cough syrup) to be given to my child, if deemed available.
  
      Signature   Date
  
  SPECIFIC MEDICAL INFORMATION
  The parish will take reasonable care to see that the following information will be held in confidence.
  
  Allergic reactions (medications, foods, plants, insects, etc.)   Type Here Immunizations: Date of last tetanus/diphtheria immunization   Type Here
  Does child have a medically prescribed diet?   Type Here
  Any physical limitations?    Type Here
  Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, bedwetting, fainting?   Type Here
  Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, H1N1, etc.? If so, date and disease or condition:   Type Here
  You should be aware of these special medical conditions of my child:Type Here
- PHOTO/VIDEO RELEASE
  
  I, First Name* , authorize St. Timothy Catholic Parish of the Diocese of San Diego, its representatives, or volunteers, to photograph or record on audio or video (tape or digital) First Name* Last Name* for purposes of furthering the mission of Youth Ministry, in this
  case, the creation of publication materials for participants in Youth Ministry at St. Timothy Catholic Parish. Photos, audio, or video may be used in printed materials and any other visual display or media. I understand that such photos and/or video recordings will be used for St. Timothy Catholic Parish related purposes and will not be used for any commercial purpose whatsoever. I therefore hereby waive any kind and all rights I may have for remuneration of any kind that could otherwise accrue for the uses of such photos and/or audio or video recordings.
  Signature* Date*
- Should be Empty:

Youth Ministry Registration (1/3)

Youth Ministry Registration (2/3)

PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER (3/3)

PHOTO/VIDEO RELEASE