Youth Ministry Registration 2021-2022
Youth Ministry is replacing permission slips for your convenience! Please register your youth for Youth Ministry- this is general information, code of conduct, waiver portion and medical release of the previous permission slips but you only fill it out ONCE per school year! Yay!!

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**Parent Typed Name Required**                                   Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19 Diocese of Little Rock- The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. St. Joseph Youth Ministry has put in place preventative measures to reduce the spread of COVID-19; however, the Program cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending the Program could increase your risk and your child(ren)’s risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the Program and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Program may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Program employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the Program or participation in Program programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the Program—including but not limited to its employees, agents, and representatives, the Diocese of Little Rock, and any Parish or School with which the Program is affiliated—of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Program, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Program event. *
IMPORTANT INFORMATION!! A checklist for upcoming events will be sent out MONTHLY to register for specific events- select which events your teen will be participating in and return it to the youth office as soon as possible (via, email, in person mailed in, fax, etc). Knowledge of attendance is necessary in order to secure the financial need, transportation, and food for each youth event. If you signed up for an event and later find you can't attend, please notify the Youth Minister. Retreats will continue to have their own registration forms. **PLEASE NOTIFY THE YOUTH MINISTER IF CHANGES HAVE BEEN MADE TO ANY OF THE AREAS BELOW THROUGHOUT THE YEAR**
Student FULL Name *
Student Age *
DOB
MM
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DD
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YYYY
Student cell phone #
Grade *
Parent FULL Name *
Parent contact information (phone # and email) *
The following are a few rules all participants are expected to follow while participating in youth events: *
Required
I (guardian) grant permission for my child (participant) to participate in the above listed event. I agree on behalf of myself, my child's other parent if known or living (parent), my child named herein or our heirs, successors, and assigns, to hold harmless and defend the Diocese of Little Rock, St. Joseph Catholic Church (its pastor, youth minister, other agents, etc.) or any representatives associated with the scheduled activity unless the parties involved were careless or negligent.   *
Required
I give my son/daughter permission to be a passenger in a protocol-ed adult chaperone's car or ride a bus (as arranged by the St. Joseph Youth Ministry) for the purpose of going to and from the event listed above. I understand all passengers in a private vehicle must wear seat belts, by my agreeing, I agree to hold harmless of neglect any adult chaperone, any staff member, the school, parish or diocese, in case of an accident occurs while on this trip. *
Required
I give permission for my son/daughter to be photographed and to publish the photo in local, diocesan and parish media, both printed and electronic. I also give the youth ministry department permission to contact my son/daughter through phone or electronic media regarding this event. *
Required
I hereby warrant to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
Of the following statements pertaining to medical matters, sign only accordance to your wishes: in the event of any 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. In the event of any emergency and you are unable to reach me, contact (name and phone #): *
Medications? *
I grant permission for medication or any type, whether prescription or nonprescription may be administered by my child unless the situation is life threatening and emergency treatment is required. *
Medical conditions and information: *
Immunizations current and up to date? *
Insurance information: Insurance carrier, Name of insured, insurance ID #, Fathers name, DOB and place of employment, Mothers name, DOB and place of employment. OR state that you do not carry medical insurance at this time. *
PARENT SIGN HERE *
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