Youth Ministry Form For Middle and High School Students

Youth Full Name*

First NameLast Name

Date of Birth*

Date

Age*

School Grade

Middle School (Edge): Ages 11–13High School (Life Teen): Ages 14–18Young Adult: Ages 19–30

Name of Father or Gardian: Person 1*

First NameLast Name

Email

example@example.com

Phone Number of Person 1:*

Please enter a valid phone number.Format: (000) 000-0000.

Name of Mother or Gardian: Person 2*

First NameLast Name

Email

example@example.com

Phone Number of Person 2:*

Please enter a valid phone number.Format: (000) 000-0000.

Work Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Information

Emergency Contact's Name

First NameLast Name

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Relationship:*

Allergies to Food? Please Specify*

Allergies to Medicine? Please Specify*

Does the youth have any allergies, chronic illness, or medical conditions? If yes, please describe. If the student requires time to take prescribed medications please explain instructions.*

Allergies to Other? Please Specify*

Informed Consent and Acknowledgement I hereby give my approval for my child/ren participation in any and all activities prepared by Holy Cross Catholic Church during the Youth and Young Adults Ministry of 2025 - 2026 year. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Holy Cross Catholic Church, and all its respective officers, staff, and volunteers from any and all liability for injuries to said child/ren arising out of participation in any of the sessions. In case of injury to said child/ren, I hereby waive all claims against Holy Cross Catholic Church and its respective officers, staff, and volunteers.

Medical Release and Authorization As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention. Permission is hereby granted to the attending physician to proceed with any medical treatment of the named student. Permission is also granted to the Holy Cross Catholic Church, including Directors, staff, and volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season for the Youth and Young Adults Ministry Year of 2025 - 2026. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of the named minor child, in my absence.

VIRTUS Program Teaching Safety - Empowering God's Children

The Archdiocese of Atlanta is committed to helping children and young people learn and grow in a healthy and safe environment. Holy Cross Catholic Church complies with Archdiocesan Safe Environment policies and procedures.

In accordance with the U.S. Bishop's Charter for the Protection of Children and Young People, the VIRTUS program Teaching Safety - Empowering God's Children is used in the Archdiocese of Atlanta. Students in grades Kindergarten through 12th grade participate in one or two lessons each year.

All employees, and volunteers who regularly work with minors receive the Safe Enrironment training, as well as ongoing training and background screening. More information can be found in the Archdiocese of Atlanta website at https://archatl.com/ministries-services/safe-environment/.

YESNO

Confirmation and Acknowledgement of the Above Information

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature of Parent/Guardian:*

Date of Signature:*

Date

YOUTH MINISTRY OF HOLY CROSS CATHOLIC CHURCH