High School-Diocese of Beaumont Jh Form 2026-27

Youth NAME last, first, middle*

MaleFemale

YOUTH ADDRESS street, city, state, zip*

Primary EMAIL*

Mother/Guardian Name *

Mother/Guardian Phone Number

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

Father/Guardian Name *

Father/Guardian Phone Number

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

LIST TWO NEIGHBORS OR RELATIVES WHO WILL ASSUME TEMPORARY CARE OF YOUR CHILD IF YOU CANNOT BE REACHED.

Name *

Phone*

Name *

Phone*

Note any health conditions such as heart disease, diabetes, eye or ear problems, epilepsy, severe allergies, chronic ailments, etc. Explanation:

Note any health conditions*

RELIGION*

CHURCH YOU ATTEND*

GRADE Fall 2026*

AGE*

DATE OF BIRTH*

PLACE OF BIRTH*

I/WE THE PARENT(S) GUARDIAN(S) OF THE ABOVE NAMED INDIVIDUAL HEREBY GIVE MY/OUR CONSENT AND APPROVAL FOR HIS/HER PARTICIPATION IN ANY AND ALL ACTIVITIES SPONSORED BY THE DIOCESE OF BEAUMONT, MOST REVEREND DAVID L. TOUPS, BISHOP OF DIOCESE OF BEAUMONT, AND/OR THIS PARISH AND/OR THIS SCHOOL, AND ANY AND ALL ORGANIZERS OR SPONSORS, INCLUDING PARTICIPATION IN ATHLETIC EVENTS. I/WE ASSUME ALL RISKS AND HAZARDS INCIDENT TO THE CONDUCT OF SUCH ACTIVITIES, INCLUDING ANY AND ALL TRANSPORTATION, AND FOR AND IN CONSIDERATION OF THE EDUCATIONAL INSTRUCTION HE/ SHE WILL RECEIVE IN CONNECTION THEREWITH, I/WE HEREBY AGREE TO RELEASE, ABSOLVE, INDEMNIFY AND HOLD HARMLESS, AND DO BY THIS INSTRUMENT RELEASE, ABSOLVE, INDEMNIFY AND HOLD HARMLESS THE DIOCESE OF BEAUMONT, MOST REVEREND DAVID L. TOUPS, BISHOP OF DIOCESE OF BEAUMONT, AND/OR THIS PARISH AND/OR THIS SCHOOL, AND ANY AND ALL ORGANIZERS OR SPONSORS, OF AND FROM ANY AND ALL LIABILITY FOR AN INJURY TO MY/OUR AFORESAID YOUTH, AND I/WE WAIVE ALL CLAIMS OF ANY KIND AGAINST ANY OR ALL OF THE ORGANIZATIONS OR PERSONS HEREINABOVE ENUMERATED, INCLUDING ANY AND ALL CLAIMS AGAINST ANY PERSONS TRANSPORTING MY/OUR CHILD TO OR FROM ANY SUCH ACTIVITIES HEREINABOVE NAMED. I WE AUTHORIZE THE PARISH AND/OR SCHOOL AND ANY AND ALL ORGANIZERS OR SPONSORS TO PERFORM A PRE-BOARDING SEARCH OF OUR SON’S/DAUGHTER’S LUGGAGE AND/OR BACKPACK AND/OR PURSE FOR ILLEGAL SUBSTANCES OR ANY ITEM WHICH MAY ENDANGER THE HEALTH OR SAFETY OF THE ORGANIZATION, ITS PARTICIPANTS OR PERSONNEL. I/WE AUTHORIZE THE PARISH AND/OR SCHOOL AND ANY AND ALL ORGANIZERS OR SPONSORS TO PERFORM A SEARCH UPON OUR SON/DAUGHTER IF HE/SHE IS SUSPECTED TO BE IN POSSESSION OF ILLEGAL SUBSTANCES OR ANY ITEM WHICH MAY ENDANGER THE HEALTH OR SAFETY OF THE ORGANIZATION, ITS PARTICIPANTS, OR PERSONNEL.*

DATE

Signature (Parent/Guardian)*

Parent Signature

Please fill in ALL blanks below. If the answer is none or does not apply, write none or N/A in that blank. Every line needs response

I hereby warrant 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, mark only those in accordance with your wishes:

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 and I understand that all financial obligations are my responsibility.

Family Doctor Name

Family Doctor: Phone*

Format: (000) 000-0000.

My child will bring all such medications, well labeled, that are necessary. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency are as follows: My child is taking the following medication at the present time. *

Medications

Dosage:

I hereby Do Not Grant Permission for medication of any type, whether prescription or nonprescription may be administered by my child unless the situation is life threatening and emergency treatment is required. (Please initial)

Initail If No nonprescription can't be given

I hereby Grant Permission for nonprescription medication (such as Tylenol, throat lozenges, cough syrup) to be given to my child, if deemed advisable. I understand that Aspirin will not be given to my son/daughter. (Please initial)

Initial if Yes nonprescription can be given

Medical Conditions Information: Diocesan personnel will take reasonable care to see that the following information will be held in confidence My son/daughter has: Has had an episode of the following or has been diagnosed: Seizures Asthma Diabetic Allergic reactions to the following food, dyes, latex etc Has a medically prescribed diet? The following physical limitations?

list medical conditions or allergies

Has a medically prescribed diet?

The following physical limitations?

Date of last tetanus/diphtheria immunization Immunizations current and up to date:

Date

You should also be aware of these special medical conditions of my child e.g. depression, anxiety, etc

Signature (Parent/Guardian) *

Date Signed*

Date

Insurance Company

Policy Carrier (Name Employer or Individual)

Policy Number

As parent/guardian, I understand that promotional pictures and videos (individual and group) will be taken during diocesan events. I give permission for my son’s/daughter’s picture to be used for promotional materials (newsletter, web page, calendars, power point, video etc in highlighting diocesan events.

Signature (Parent/Guardian)

Date

Upload CopyImage of Health Insurance Card, Front

Upload CopyImage of Health Insurance Card, Back

Upload CopyImage of Baptism Certificate for Newly Enrolled Students only

EXHIBIT J-h

Diocese of Beaumont

Youth Registration, Consent, Liability Waiver

Medical Matters

Emergency Medical Treatment

Medications

Information

Video/Photography Consent