Youth Service Weekend at Rock Point Registration

Youth Service Weekend at Rock Point Registration
Registration Type*
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Contact Information
Parent/Guardian Email*
example@example.com
Parent/Guardian Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Participant Registration
Name of Registrant*

First NameLast Name
Registrant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Registrant Date of Birth*

MonthDayYear
Date
Grade
If 'Other,' please explain
Congregation*
Gender
Is there anything you would like the adult staff to know about your gender, gender identity, or pronouns?
Medical Information
Food Allergies or Restrictions*
Important medical information (not related to food) and special needs
List all medications registrant has permission to bring. Medications must come in original packaging with clear dosing instructions. Staff will contact parent/guardian to set up a medical disbursement plan while youth is participating in event.
Health Insurance Company & Policy Number*
Primary Care Physician's Name*
Physician's Phone*
Parent/Guardian Consent
Photos of my child may be used for publicity purposes, including on social media.*
Videos of my child may be used for publicity purposes, including on social media.*
I give permission for my child to participate in Youth Events. I absolve the Diocese(s), the sites and churches, and their employees and volunteers from responsibility for accident or injury which may occur during any aspect of this event, including transportation to, from and during the event. I give permission to the adults to give medications and to provide or get emergency medical treatment, and I will be financially responsible for such treatment. (Parent/Guardian - typing your name below indicates your agreement. This is required for your child to attend)*
Payment
This event is being presented at a sliding scale for participants of $50, $75, or $100. How would you like to pay:*
Should be Empty:

Youth Service Weekend at Rock Point Registration

Parent/Guardian Contact Information

Participant Registration

Medical Information

Parent/Guardian Consent

Payment