St. Dominic CYO Membership Renewal for 2025-2026

St. Dominic CYO Membership Renewal for 2025-2026
Student Information
Youth Name*

First NameLast Name
Cell Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Has any contact or parental information changed in the past year? If so, please note below.

Medical Information
Section I: Medical Matters

As the parent/legal guardian of the above named child, who is currently associated with St. Dominic CYO. I hereby authorize Courtney Jansen or his/her assistants to carry out the wishes I have named (herein) in areas of emergency medical treatment and other cases of illness.

This authorization inclusively extends from May 1, 2025, through June 30, 2026. 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.
Signature*

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Section II: 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 wish 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 numbers listed herein, contact:
Emergency Medical Contact

First NameLast Name
Relationship to Student
Phone Number
Please enter a valid phone number.
Family Doctor

First NameLast Name
Phone Number
Please enter a valid phone number.
Family Health Plan Carrier
Policy Number
Signature

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Section III: Medications

Select only those options that are applicable.
Which of the following applies to your student?*

My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage will be provided.My child is presently taking no medication.
Please list medication dosage, frequency, etc. if applicable.
What permission do you give for non-prescription medication?*

I hereby grant permission for non-prescription medication (such as Tylenol, throat lozenges, cough syrup, etc.) to be given to my child, if deemed appropriate.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*

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Section IV: Medical Information

The parish will take reasonable care to see that the following information will be held in confidence.
Does your student have any allergies (medications, foods, plants, etc.)? If so, please list.
Date of last tetanus/diphtheria immunization:
Does your student have a medically prescribed diet? If so, please describe.
Does your student have any physical limitations? If so, please describe.
Is your student subject to chronic homesickness, emotional reactions to new situations, etc.? If so, please describe.
Has your student recently been exposed to contagious disease or conditions such as mumps, measles, chickenpox, etc.? If so, please list date and disease/condition.
Are there any special medical conditions we should be aware of? If so, please describe.

Photo Authorization

Authorization for use of name, photograph, and/or likeness and/or information and release, defense, indemnity, and hold harmless.
For valuable consideration acknowledged and the dues paid as part of the youth group registration, we/I, parents of Youth First Name Last Name , hereby authorize The Roman Catholic Church of the Archdiocese of New Orleans as operator of the Catholic Youth Organization (hereinafter “CYO”) and the St. Dominic Catholic Church (hereinafter “Church”), to use the name, photograph and/or likeness of our child in any advertisements and/or publicity in newspapers, church and school bulletins, and/or literature and/or on the CYO and/or Church website and/or in any televised or video media, including but not limited to the any videos on the internet posted by CYO and/or Church, as determined in the sole discretion of CYO and/or Church.

We/I agree to defend, indemnify and hold harmless The Roman Catholic Church of the Archdiocese of New Orleans as operator of the Catholic Youth Organization and St. Dominic Catholic Church, their members, directors, officers, pastor(s), principal(s), teachers, employees, agents and assigns (hereinafter, collectively, “Releases”) from any liability or damages of any kind or type (including but not limited to mental, physical, emotional or economic damages) which may arise from the authorized use set forth above, including but not limited to any claims or causes of action arising in negligence or intentional fault, including but not limited to any claims or causes of action of defamation or invasion of privacy.
Signature*

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Code of Conduct
My child who is joining CYO, and I, are aware of and accept the St. Dominic CYO Code of Conduct available on www.stdominiccyo.org
Signature*

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Payment Details

My Products*

CYO New Member Dues

$45.00 Quantity

Summer Trip Participant or PMT Member Renewal fee included in trip cost or member dues

$ Free Quantity

Total

$0.00

Credit Card

Should be Empty:

St. Dominic CYO Membership Renewal for 2025-2026

Student Information

Medical Information

Section I: Medical Matters

Section II: Emergency Medical Treatment

Section III: Medications

Section IV: Medical Information

Photo Authorization

Code of Conduct

Payment Details

Credit Card