Teens for Life 2026 Registration

Teens for Life 2026 Registration

*please complete one form for each participant
Name of Youth Participant:*

First NameLast Name
Nickname (if applicable):
Grade as of 2025-2026 School Year: *
*based upon age on September 1, 2025
Birth Date:*

MonthDayYear
1314151617
MaleFemale
School as of 2025-2026 Academic Year *
Type school name
Youth Participant Email (if applicable):
example@example.com
*Any communication with teen participants will include both a parent and a St. Mary of the Mills staff member as copied recipients.

Medical Information
The parish will take reasonable care to see that the following information will be held in confidence.
Health Insurance Carrier:
Health Insurance Policy Number:
Allergies (medications, foods, plants, insects, etc): *
Please put NONE if it does not apply.
Does your child have a medically prescribed diet? If yes, please explain.*
Please put NO if it does not apply.
Physical limitations:*
Please put NONE if it does not apply.
Is your child subject to chronic homesickness, emotional reactions to new situations, and/or fainting? If so, please describe.*
Please put NO if it does not apply.
Does your child have an IEP at school? If yes, please explain. *
Please put NO if it does not apply.
Has your child recently been exposed to contagious viruses, disease, or other conditions? If so, please explain.*
Please put NO if it does not apply.
Is there anything you would like us to know about your child?
Medical Releases - Teens for Life 2026
Of the following statements pertaining to medical matters, please sign only those that are applicable.

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.
Signature of Parent/Guardian

Clear
I Agree. (By checking this box and typing your name above, you have agreed that this is your electronic signature.)
Date

MonthDayYear
Date
Other Medical Treatment: In the event it comes to the attention of the parish, its officers, directors and agents, and the Archdiocese of Washington, chaperons, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called before treatment is given.
Signature of Parent/Guardian

Clear
I Agree. (By checking this box and typing your name above, you have agreed that this is your electronic signature.)
Date

MonthDayYear
Date
Medications: 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, are as follows:
Signature of Parent/Guardian

Clear
I Agree. (By checking this box and typing your name above, you have agreed that this is your electronic signature.)
Date

MonthDayYear
Date
No Medications: 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 of Parent/Guardian

Clear
I Agree. (By checking this box and typing your name above, you have agreed that this is your electronic signature.)
Date

MonthDayYear
Date
Permission for non-prescription medication: I hereby grant permission for non-prescription medication (such as non-aspirin products, i.e. acetaminophen or ibuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.
Signature of Parent/Guardian

Clear
I Agree. (By checking this box and typing your name above, you have agreed that this is your electronic signature.)
Date

MonthDayYear
Date

Family Information
Parent/Guardian Primary Contact Name:*
Full Name
Parent/Guardian Email (the best email for communicating with you):*
example@example.com
Primary Address of the Youth Participant:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Cell Phone # (best number for communicating with you):*
XXX- XXX-XXXX
Primary Language Spoken at Home:*
EnglishSpanishOther
Emergency Contact
Emergency Contact Name (other than parent/guardian):*
Full Name
Relationship to the child:*
Emergency Contact Primary Phone Number:*

Publicity Release

Teens for Life 2026
Publicity Release Form

---------------------------------------------

Teens for Life 2026
St. Mary of the Mills Catholic Church and the Archdiocese of Washington have opportunities throughout the year to promote Catholic faith formation through news stories in radio, TV, print and electronic media.

Permission is hereby granted St. Mary of the Mills Catholic Church and the Archdiocese of Washington to use the voice/audio recordings, photographs, video and quotations of Child's Full Name to assist in community awareness, educational efforts and related public relations purposes, including media coverage of parish events and activities and public relations/advertising that may include brochures, posters, print, radio, internet, TV or any other electronic media.

In exchange for the opportunity to participate in the community awareness programs, educational effort and related publicity endeavors of St. Mary of the Mills Catholic Church and the Archdiocese of Washington, I hereby, agree to release and hold harmless St. Mary of the Mills Catholic Church and the Archdiocese of Washington and their agents, servants and employees from any and all claims, demands, causes of action and/or liability of whatever kind or nature arising out of or connected to the use of said voice/audio recordings, photographs, video and quotations.

I hereby waive any right to compensation, fee or royalty for myself, the participant/student or our successors, heirs or assigns in connection with the production or use of the aforesaid materials.
Signature of Parent/Guardian

Clear
I Agree. (By checking this box and typing your name above, you have agreed that this is your electronic signature.)
Date

MonthDayYear
Date

Hold Harmless

Teens for Life 2026
As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“participant”). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St. Mary of the Mills it’s officers, directors, employees and agents, and the Archdiocese of Washington, its employees and agents, chaperons, or representatives associated with the event, from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors and agents, and the Archdiocese of Washington, its employees and agents and chaperons, or representative associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/diocese.
Signature of Parent/Guardian*

Clear
I Agree. (By checking this box and typing your name above, you have agreed that this is your electronic signature.)
Date*

MonthDayYear
Date

YesNo
Should be Empty:

Teens for Life 2026 Registration

Medical Information

Medical Releases - Teens for Life 2026

Family Information

Emergency Contact

Publicity Release

Hold Harmless