Family Fully Alive & YOUTH GROUP REGISTRATION

Family Fully Alive & YOUTH GROUP REGISTRATION
CATHOLIC CHURCH OF THE HOLY SPIRIT
PAID AMOUNT via Church Website or check or cash
Please read carefully and complete required fields.
Registration Date

MonthDayYear
Date
CHILD(REN'S) LAST NAME
Household Email Address
example@example.com
Mailing Address City Zip
Fathers Full Name
Father's Cell Phone Number
Please enter a valid phone number.
Mothers Full Name
Mother's Cell Phone Number
Please enter a valid phone number.
Which Parent(s) will be attending Families Fully Alive with your child?
EMERGENCY CONTACT (OTHER THAN PARENT) IF NEITHER PARENT CAN BE REACHED:
Name of Emergency Contact
Emergency Contact's Phone Number
Please enter a valid phone number.
*Please submit a copy of each child's baptism certificate along with registration.

I am aware that I may request an Opt-Out Form to exclude my child from participating in the Safe Environment / Abuse Prevention Training class.
initial
First Child's FIRST, MIDDLE, and LAST Name
1st Child's Grade in School
1st Child's Age and Date of Birth
Baptized Catholic?

YesNo
Baptized in Another Faith

YesNo
Received First Eucharist?

YesNo
Received Confirmation?

YesNo
2nd Child's FIRST, MIDDLE, and LAST Name
2nd Child's Grade in School
2nd Child's Age and Date of Birth
Baptized Catholic?

YesNo
Baptized in Another Faith

YesNo
Received First Eucharist?

YesNo
Received Confirmation?

YesNo
3rd Child's FIRST, MIDDLE, and LAST Name
3rd Child's Grade in School
3rd Child's Age and Date of Birth
Baptized Catholic?

YesNo
Baptized in Another Faith

YesNo
Received First Eucharist?

YesNo
Received Confirmation?

YesNo
4th Child's FIRST, MIDDLE, and LAST Name
4th Child's Grade in School
4th Child's Age and Date of Birth
Baptized Catholic?

YesNo
Baptized in Another Faith

YesNo
Received First Eucharist?

YesNo
Received Confirmation?

YesNo
5th Child's FIRST, MIDDLE, and LAST Name
5th Child's Grade in School
5th Child's Age and Date of Birth
Baptized Catholic?

YesNo
Baptized in Another Faith

YesNo
Received First Eucharist?

YesNo
Received Confirmation?

YesNo
6th Child's FIRST, MIDDLE, and LAST Name
6th Child's Grade in School
6th Child's Age and Date of Birth
Baptized Catholic?

YesNo
Baptized in Another Faith

YesNo
Received First Eucharist?

YesNo
Received Confirmation?

YesNo
PLEASE COMPLETE THE REVERSE SIDE
IN OUR EFFORTS TO BETTER SERVE THE EDUCATIONAL NEEDS OF YOUR CHILDREN PLEASE PROVIDE THE FOLLOWING INFORMATION:

Does your child(ren) have allergies, learning and/or physical disabilities? If yes, please specify. If you need more than three lines, please let us know and we will provide an additional page.
First Child's Name
First Child's Allergies/Disabilities
Second Child's Name
Second Child's Allergies/Disabilities
Third Child's Name
Third Child's Allergies/Disabilities
Our family is registered with this parish:

YesNo
If not registered, please request and complete the from at this link to the Parish Registration Form today. https://form.jotform.com/232328613396055
Our Family Attends Mass

WeeklyMonthlySeldomNever
Our children attend Faith Formation last year:

WeeklyMonthlySeldomNever
Our children will attend Faith Formation this year:

WeeklyMonthlySeldomNever
I can help/volunteer:

Teach Faith Formation weeklyOccasionally sub in classSpirit NiteVBS
Other ways I can help Holy Spirit Catholic Church and get involved:
BY LISTING THE NAMES OF THE PEOPLE BELOW YOU ARE ALLOWING OUR FAITH FORMATION TEACHERS TO RELEASE YOUR CHILDREN TO THEM:
NAME & RELATIONSHIP
NAME & RELATIONSHIP
NAME & RELATIONSHIP
NAME & RELATIONSHIP
NAME & RELATIONSHIP
THE CATHOLIC DIOCESE OF PENSCOLA TALLAHASSEE
It is the promise and commitment of the Diocese of Pensacola-Tallahassee to use pictures and videos from Diocesan and/or parish youth events in a dignified and respectful manner. I hereby authorize the Diocese of Pensacola-Tallahassee, including its parishes, schools, and institutions (hereinafter referred to as "Diocese of Pensacola-Tallahassee") to use, prepare, reproduce, record, video tape, publish, distribute, broadcast, electronically store, and exhibit my name, image, portrait, likeness, words, and/or voice in connection with interviews, sessions, or events conducted, sponsored, or arranged by the Diocese of Pensacola-Tallahassee and its employees, volunteers, and agents. I acknowledge that any notes, photographs, motion pictures, digital images, recordings, or other media format taken of me will become the property of the Diocese of Pensacola-Tallahassee, and I specifically waive any right to compensation for the foregoing. I understand that my likeness, name, image, or voice may be used by the Diocese of Pensacola-Tallahassee without limitation for any professional purpose, now or in the future, and I consent to the same. This permission extends to any authorized print or broadcast media organization that may participate in such preparation, use, reproduction, publication, or distribution. I release the Diocese of Pensacola-Tallahassee and its employees, volunteers, agents, and designees from liability for any violation of any personal or proprietary right I may have in connection with such use. I also hereby waive any right I may have to inspect and approve in advance the photographs, videos, sound recordings, or publications or media in which I am included. I agree to release the Diocese of Pensacola-Tallahassee and its employees, volunteers, agents and designees from any liability by virtue of the use of the photographs or video recordings, regardless of any blurring, distortion, optical illusion, or alteration which may occur when the photographs or videos are taken, printed, or displayed. A photocopy of this release shall be as valid and enforceable as the original.
Children's Names
Address
City
State
Zip
Telephone Number
Signature

Clear
Date

MonthDayYear
Date
*Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Parent Guardian print name
I DO NOT authorize or release the Diocese of Pensacola-Tallahassee, to use, prepare, reproduce, record, video tape, publish, distribute, broadcast, electronically store, and exhibit my name, image, portrait, likeness, words, and/or voice in connection with interviews, sessions, or events conducted, sponsored, or arranged by the Diocese of Pensacola- Tallahassee and its employees, volunteers, and agents.
Signature

Clear
Date

MonthDayYear
Date
*ParentGuardian Signature

Clear
Date

MonthDayYear
Date
Parent Guardian print name
*The consent and signature of a parent or guardian is required for minors (under the age of 18).

Pastoral Center I 11 North B Street, Pensacola, FL 32502 I (850) 435-3500 ptdiocese.org
ANNUAL MEDICAL INFORMATION FORM
Children's Full Names

First NamesLast Names
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex of Children
Dates of Birth for Children
Schools
Doctor's Name
Doctor's Phone Number
Please enter a valid phone number.
Father/Guardians full name
Home Phone
Cell Phone
Home address
Work Phone
Mother/Guardian's full name
Cell Phone
Home address
Place of business address
Work Phone
Relative or friend to contact if unable to reach parent/guardian in the event of emergency:
Name & Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
Insurance Carrier
Policy Number
Insurance provided by which parent/place of work?
Insurance Company Phone Number
MEDICATIONS: (EITHER A PHYSICIAN'S PRESCRIPTION OR A PARENT NOTE MUST ACCOMPANY ALL MEDICATIONS.

PRESCRIPTION / NOTE SHOULD BE ATTACHED TO THIS FORM My child is taking the following medication(s): Description Dosage
Description of Medication
Dosage
Description of Medication
Dosage
I hereby grant permission for non-prescription medications to be given, if deemed appropriate.
Drug Allergies
Other Allergies (food, plants, insects, etc)
Other known diseases, disorders, or disabilities
If you would like your youth to participate in parish activities, please sign and return the following statement of consent and release of liability. As parent or legal guardian, you remain fully responsible for any legal responsibility which may result from any personal actions taken by your youth. In consideration for the opportunity for my child to participate in parish activities, and fully recognizing that such an undertaking involves an element of risk, we assume all risks and hazards incidental to such participation and do hereby release, absolve, indemnify and agree to hold harmless the Diocese of Pensacola- Tallahassee and Holy Spirit Parish, and their employees, agents, volunteers, and other persons acting on their behalf. Neither the Diocese of Pensacola-Tallahassee, Holy Spirit Parish, nor said agents, employees, or volunteers, shall be held financially responsible for any injury, illness or death incurred as a direct or indirect result of this activity. We the undersigned have read this release and understand all its terms and execute it voluntarily and with full knowledge of its significance.

EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I/we hereby authorize the Diocese of Pensacola-Tallahassee, and Holy Spirit Parish, through its authorized representatives, to transport my child to a hospital or other doctor's office or medical facility for emergency medical attention. I/ We additionally authorize such representatives of the Diocese and/or School to obtain and give consent to whatever medical treatment the representative deems necessary, including the administering of anesthetic and surgery, and do hereby release the Diocese and Holy Spirit Parish, and their authorized representatives from any and all claims which may arise from the above-referenced obtaining and consenting to medical treatment. I/We wish to be advised, if possible, prior to the providing of any non-emergency medical treatment by any physician or hospital.

Emergency Contact and relation to participant Address and phone number
Signature of ParentGuardian

Clear
Date

MonthDayYear
Date
This form is to be kept at the parish and renewed annually
For Family Fully Alive Cost is $50 per family of 3 or less, $10 for each additional family member.

Scholarships avaliable please email Abbie Lim dre@hs.ptdiocese.org

For Edge and Lifeteen $25 per child.

Pay Online Here

OR

Make checks payable to Catholic Church of the Holy Spirit.
Should be Empty:

Family Fully Alive & YOUTH GROUP REGISTRATION

CATHOLIC CHURCH OF THE HOLY SPIRIT

EMERGENCY CONTACT (OTHER THAN PARENT) IF NEITHER PARENT CAN BE REACHED:

PLEASE COMPLETE THE REVERSE SIDE

THE CATHOLIC DIOCESE OF PENSCOLA TALLAHASSEE

ANNUAL MEDICAL INFORMATION FORM

I hereby grant permission for non-prescription medications to be given, if deemed appropriate.