2021/2022 High School Youth Ministry Registration for St Thomas/St John

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Child Information

Email *

Child Information

Child's First Name *

Child's Last Name *

Gender *

Female

Male

Birth Date *

YYYY

Year in School During 2021-2022 *

Freshman

Sophomore

Junior

Senior

School Child Attends *

Full Home Address *

Student Email Address *

Allergies / Health/ Learning Challenges *

Parent Information

Mother/Guardian 1 First and Last Name *

Father/Guardian 2 First and Last Name *

Mother/Guardian 1 Email Address *

Father/Guardian 2 Email Address *

Mother/Guardian 1 Phone Number *

Father/Guardian 2 Phone Number *

PROGRAM CHOICE

What Program(s) Will Your Child Be Joining? *

In-person Youth group: Wednesday Nights: 7:00-8:30PM

EMERGENCY CONTACT INFORMATION

Name of Emergency Contact ( Not parents/guardians) *

Phone Number of Emergency contact *

PERMISSION AND DISCLAIMERS

Included in this section are Participation Release Form, Diocese of Lansing - Media Release Form, Communication Release Form. The full language or a hard copy can be sent to you on request (skurt@elcatholics.org). Your YES will act as a binding personal signature and date for the following:

(My student’s name as indicated above) has my permission to participate in activities in the St. Thomas Aquinas and St. John Church and Student Center Parish Religious Education and Youth Ministry Program during the 2021/2022 school year. I understand that all activities are sponsored by the parish and supervised by parish volunteers and/or staff. Transportation to and from the parish is the parents’ or guardian’s responsibility *

Yes, I give permission

I give permission to the Diocese of Lansing and St Thomas / St John to use the image of my child, (students name as indicated above) in its promotional materials. I understand that these materials maybe presented in any format, including paper, electronic, and all other media. Neither my child nor I will receive any money in exchange for this permission; the Diocese of Lansing will own the copyright to these materials, and I waive on behalf of my child the right to sue for use of my child’s image in good faith by the Diocese of Lansing. *

Yes, I give permission

I understand that the staff of St. Thomas Aquinas Parish/St. John may be communicating with members of our family. If you, as parent or guardian, have any particular boundaries of which we should be aware, or if there are any common media that you want us not to use in communicating with you or your child, please let us know in the "other" answer *

Yes, I give my permission

Other:

HEALTH HISTORY FORM

I understand that by submitting this form electronically, my typed full name, acts as my signature *

Yes

Medical Conditions *

My child has no physical, medical, or other condition that will affect or be affected by participation in Religious Education Activites. Further, my child has no allergy that should be disclosed to emergency personnel.

My child does have a physical, medical, or other condition that will affect or be affected by participation in Religious Education Activities. Or my child has an allergy that should be disclosed to emergency medical personnel. (give details below)

If your child does have a condition, provide a full explanation in this box and type in your full name at the end to act as your signature.

PERMISSION FOR DISCLOSURE AND EMERGENCY MEDICAL TREATMENT: The parish has my permission, in an emergency when parents or guardians cannot be contacted, to take my child to a hospital emergency room. The hospital and its medical staff have my authorization to provide treatment that a physician deems necessary for the well-being of my child. I will be contacted as soon as possible and will be advised prior to any further treatment by the hospital or doctor. I understand and agree that I will be responsible for the emergency medical charges. I understand that by entering my full name, this acts as my signature. *Please enter your NAME and today's DATE *

Insurance Provider / Health Plan *

Health Plan Number *

REGISTRATION DONATION

Suggested Donation Per Child in High School Youth Ministry is $25 or more per child for the whole year. Donations can be made in person, by check, or online. For students that are unable to make a donation, full scholarships are always provided - we are happy to have everyone join Youth Ministry, regardless of financial situation!

For Youth Ministry this year, we will not be accessing a regular "fee" per student as has been done in past years. Instead, we will ask all those who register to make the donation amount you are comfortable making to support our ministry. Your donation will be used to purchase food and snacks at all Youth Groups, pay speakers stipends for talks, pay for materials and videos and registrations, and help support our retreat ministries. Please prayerfully consider what you donation you are able to make to support our Youth Ministry.

Payment *

We will make a $25 donation per child

We will make a $50 donation per child

We will make a $75 donation per child

We will make a $100 donation per child

I would like a scholarship for my child to attend high school youth ministry

Other:

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