Updated Access: 2022-2023 Middle School Youth Ministry Registration: St. Thomas Aquinas Parish & St. John Church and Student Center

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Email *

Child Information

Child's First Name *

Child's Last Name *

Gender *

Female

Male

Birth Date *

YYYY

Grade during 2022-23 School Year *

6th

7th

8th

School Child Attends *

Full Home Address *

Student Email Address *

Allergies/Heath/Learning Challenges *

Parent/Guardian Information

Parent/Guardian 1 - First Name *

Parent/Guardian 1 - Last Name *

Parent/Guardian 1 - Phone Number *

Parent/Guardian 1 - Email *

Relationship to Child *

Mother

Father

Other:

Parent/Guardian 2 - First Name

Parent/Guardian 2 - Last Name

Parent/Guardian 2 - Email

Parent/Guardian 2 - Phone Number

Relationship to Child

Mother

Father

Other:

Clear selection

Emergency Contact Information

These are additional contacts if the parent/guardian cannot be reached!

Name of Emergency Contact 1 (Not parent/guardian) *

Emergency Contact 1 Phone Number (Not parent/guardian) *

Name of Emergency Contact 2 (Not parent/guardian) *

Emergency Contact 2 Phone Number (Not parent/guardian) *

Permission and Disclaimers

Included in this section are the Participation Release Form, Diocese of Lansing - Media Release Form, and Communication Release Form. The full language or a hard copy can be sent to you on request (jpinkowski@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 2022-23 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.

No, I do not give permission.

I give permission to the Diocese of Lansing and St. Thomas Aquinas and 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.

No, I do not 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 permission.

No, I do not give permission.

Other:

Yes, I give permission.

No, I do not give permission.

Other:

Health History Form

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

Yes, I understand.

No, I do not understand.

Medical Condition(s) *

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 health condition, please provide a full explanation in this box, or type "NA". (*Type in your full name and today's date 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 and date, this acts as my signature. (*Type in your full name and today's date at the end to act as your signature.*) *

Insurance Provider / Health Plan *

Insurance / Health Plan Number *

Registration Donation

Suggested Donation Per Child in Middle School Youth Ministry is $30 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 $30 donation.

We will make a $50 donation.

We will make a $75 donation.

We will make a $100 donation.

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

Other:

Send me a copy of my responses.

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