High School Youth Group Registration & Release Form*

Second Child's Name

First NameMiddle NameLast Name
Second Child's Preferred Name:
If different than teen's name field...
Child's Gender
Second Child's School
Second Child's Grade
Second Child's Birthday

MonthDayYear
Date
Second Child's T-Shirt Size
Ex. Adult Small
Has your child celebrated the Sacrament of Confirmation?
If yes, please indicate name of Church and date.
Would you like your child to prepare to celebrate the Sacrament of Confirmation in April 2027?
Second Child's Email
example@example.com
Second Child's Cell
Please enter a valid phone number.Format: (000) 000-0000.
May we communicate with your second child via group emails with other Youth Ministry Team members and other teens?
May we communicate with your second child via group texts and Remind with other Youth Ministry Team members and other teens?
Food or Other Allergy (including dietary restrictions)
Second Child
Chronic Medical Condition (e.g., epilepsy, diabetes, etc.)
Second Child
Learning Disability
Second Child
Please let us know if there is anything else we should know about your child...
Second Child

Parent/Guardian Info

There will be an option to add an additional parent at the bottom of the page.
Parent/Guardian's Name

First NameLast Name
Parent/Guardian's Email
example@example.com
Parent/Guardian's Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Type of Primary Phone
Parent/Guardian's Secondary Number
Please enter a valid phone number.Format: (000) 000-0000.
Type of Secondary Phone
Parent/Guardian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like to add information for an additional parent or guardian

Additional Parent/Guardian Info
Parent/Guardian's Name

First NameLast Name
Parent/Guardian's Email (if different from other parent)
example@example.com
Parent/Guardian's Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Type for Primary Phone
Parent/Guardian's Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Type for Secondary Phone
Address (if different from other parent/guardian)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Info
Emergency Contact Name (other than parent/guardian)

First NameLast Name
Emergency Contacts Relation to Teen
Emergency Contact's Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Family Doctor / Practice Name
Insurance Information
What parent/guardian is this insurance under?
Medical Insurance Company
Group #
Plan #
I.D. #

Archdiocesan Policy for Youth Activities

This waiver is a form required by the Archdiocese of Cincinnati. It will be required for all Bellarmine Youth Events.
1. I, the custodial parent/legal guardian of __________________________________________ (the “Child”), give permission for my Child to participate in the activity described on the Activity Information Form (the “Activity”) and release from all liability, indemnify, and hold harmless St. Robert Bellarmine Parish (aka Bellarmine Chapel) (“Parish and School”), the Archdiocese of Cincinnati (the “Archdiocese”), the Archbishop of Cincinnati (the “Archbishop”), both individually and as trustee for the Archdiocese, all parishes and schools within the Archdiocese, and all of their agents, representatives, volunteers, and employees from any and all liability, claims, judgments, damages, costs and expenses, including attorneys’ fees, arising out of any injury, illness, infectious and/or communicable disease (such as MRSA, influenza, or COVID-19), or death, (including any injury, illness, infectious and/or communicable disease, or death caused by the negligence of Parish and School, the Archbishop, the Archdiocese, any parish or school within the Archdiocese, or any of their agents, representatives, volunteers, or employees) incurred by my Child while participating in the Activity, traveling to or from the Activity, or while using the facilities and equipment of the Parish and School. I further agree not to bring or prosecute or allow to be brought or prosecuted (including, but not limited to, prosecution through subrogation) in my name, or on behalf of my Child, any claims, lawsuits, or actions against Parish and School, the Archbishop, the Archdiocese, all parishes and schools within the Archdiocese, or their agents, representatives, volunteers, and employees.
2. I understand that my Child’s participation in the Activity is purely voluntary and is a privilege and not a right, and that my Child, and I on behalf of my Child, agree to my Child’s participation in the Activity in spite of the risks of injury, illness, infectious and/or communicable disease (such as MRSA, influenza, or COVID-19), and death. I agree that if my Child has underlying heath concerns which may place him/her at greater risk of contracting COVID-19 or that would possibly increase the severity of illness if COVID-19 is contracted, then my Child and I will consult with a health care professional before participating in the Activity.
3. I agree to instruct my Child to cooperate with the agents of Parish and School and/or the Archdiocese who are in charge of the Activity.
4. I authorize the agents of Parish and School and/or the Archdiocese who are acting as leaders of the Activity to seek medical treatment for my Child in the event of any injury, illness, or medical emergency during the Activity or related travel. I understand that the agents of Parish and School and/or the Archdiocese will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my Child.
5. Please indicate. "I agree" or "I do not agree" that Parish and School and/or the Archdiocese may use my Child’s portrait or photograph for promotional purposes, website, and office functions.
Child's Portrait or Photograph...
6. Please indicate, "I agree" or "I do not agree" that Parish and School and/or the Archdiocese may use social media and technology to communicate with my Child regarding parish/school related ministry activities.
Social Media Use
7. This Permission, Release, and Authorization is intended to be as broad and inclusive as permitted by the law of the State of Ohio, and if any portion hereof is declared invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This Permission, Release, and Authorization shall be construed in accordance with the laws of the State of Ohio, excluding, and irrespective of, any choice of law principles to the contrary.
8. Parish and School, the Archdiocese, the Archbishop and their agents, employees, and volunteers shall have no liability whatsoever in the event the Activity is cancelled due, in whole or in part, to any present or future pandemic, epidemic, widespread disease or illness, public health concern, or circumstances arising therefrom, or from actions taken by any governmental or municipal authority to prevent, avoid, or mitigate the impacts thereof.
I have carefully read and understand and accept the terms and conditions stated herein and I acknowledge and agree that this Permission, Release, and Authorization to Seek Medical Treatment shall be effective and binding upon me, my Child, and our personal representatives, estates, assigns, heirs, and next of kin. I have signed below of my own free will.
By selecting 'I AGREE' above and signing your name here, this counts as a legal signature and acknowledges agreement to the aforementioned terms.
Do you agree with the Archdiocesan Policy for Youth Activities?

* The link for payment will be on the Thank You page once you complete the registration form. But do not let any suggested fees or registration fees stop you from indicating interest.
By signing and dating below, I affirm that I have reviewed and updated the information above for my child for the 2025-2026 school year.
2026 - 2027 Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Parish	Bellarmine Chapel
Program	Youth Group
Starting Date	August
Ending Date	May
Suggested Fee	$100 first child (enrolling in GIFT, EDGE, or High School Youth Group), $80 additional children* (
Usual Location	Xavier University Campus
Usual Day/Time	Sundays 5:15-6:45
Routine Activities	Catechesis: Learning about our Faith; Social events; Service events; Other Additional Programs, Confirmation prep, etc...
Group Leader Phone
Other Information	Some youth group programming may occur off campus. These programs will require a seperate permission form and may require transportation. For questions about programming for kids in 9th to 12th grade, please contact youthministry@bellarminechapel.org.

High School Youth Ministry Registration & Medical Release

Parent/Guardian Info

Additional Parent/Guardian Info

Emergency Info

Insurance Information

Archdiocesan Policy for Youth Activities

3. I agree to instruct my Child to cooperate with the agents of Parish and School and/or the Archdiocese who are in charge of the Activity.

5. Please indicate. "I agree" or "I do not agree" that Parish and School and/or the Archdiocese may use my Child’s portrait or photograph for promotional purposes, website, and office functions.

6. Please indicate, "I agree" or "I do not agree" that Parish and School and/or the Archdiocese may use social media and technology to communicate with my Child regarding parish/school related ministry activities.

By selecting 'I AGREE' above and signing your name here, this counts as a legal signature and acknowledges agreement to the aforementioned terms.