2019-2020 A.C.T.S. YOUTH MINISTRY PROGRAM REGISTRATION

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Use this form to register for our Friday Night Program.

Email *

CHILD'S LAST NAME / APELLIDO DE SU HIJO/A *

CHILD'S FIRST NAME / PRIMER NOMBRE DE SU HIJO/A *

HOME PHONE / TELE DE CASA

CHILD'S CELL PHONE / CELL DE NIÑO/A

CHILD'S EMAIL/ CORREO ELETRONICO DE NIÑO/A

CHILD'S SCHOOL / ESCUELA DE NIÑO/A *

CHILD'S CURRENT GRADE /GRADO DE NIÑO/A *

DATE OF BIRTH / FECHA DE NACIMIENTO *

YYYY

T-Shirt Size (all sizes are adult) If you would like to have a T-shirt, please send $15. Make Check Payable to St. Richard Congregation

XXL

XXXL

Other:

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ADDRESS / DOMICILIO *

FATHER'S LAST NAME / APELLIDO DE PAPA

FATHER'S FIRST NAME / PRIMER NOMBRE DE PAPA *

FATHER'S CELL PHONE/ NUMERO CEL DE PAPA

MOTHER'S LAST NAME / APELLIDO DE MAMA

MOTHER'S FIRST NAME/ PRIMER NOMBRE DE MAMA

MOTHER'S CELL PHONE/ NUMERO CEL DE MAMA

MOTHER'S EMAIL / CORREO ELETRONICO DE MAMA

EMERGENCY CONTACT / CONTACTO DE EMERGENCIA *

EMERGENCY CONTACT PHONE / TELEFONO *

AGREEMENT *

By Checking this box I am certifying that I am 18 YEARS of age or older and are the Parent / Guardian of the above referenced child.

Required

PERMISSION *

I consent to the participation of my CHILD/WARD in ACTS RACINE YOUTH MINISTRY ACTIVITIES. In consideration for my CHILD/WARD's participation, I agree to reimburse and indemnify the ACTS (understood to include The Archdiocese of Milwaukee) for all reasonable legal and court fees incurred by ACTS YOUTH MINISTRY in defending a lawsuit that I or my CHILD/WARD may bring against the PARISH/SCHOOL which relates ANY ACTS Youth Minstry Activitty is found not legally liable by the courts and prevails in the lawsuit. If the PARISH/SCHOOL is found legally liable for injuries sustained by CHILD/WARD, this paragraph will not apply. I certify that I have an understanding of this agreement and any risks and hazards associated with the ACTIVITY described above that my CHILD/WARD will be participating in. I further understand that I had the opportunity to fully discuss this agreement with a representative of the PARISH/SCHOOL to clarify any concerns or questions about the ACTIVITIES or this agreement that I may have had.

Required

PHOTO RELEASE *

I hereby consent that any still or electronic image and/or audio recording, in which I or my child may appear, may be used by ACTS Youth Ministry, and/or by the Archdiocese of Milwaukee. I understand that these materials are being used for promotion of ACTS Youth Ministry. and/or the Archdiocese of Milwaukee. The images and/or recordings may be used to support recruitment, fundraising, evangelization and other communication efforts. I release the staff and volunteers and I understand and agree that the use of my picture is not an invasion of privacy. Neither I, nor anyone claiming to be speaking on my behalf, will later object to the Archdiocese’s use of this/these photographs. I give permission to have my/my child(ren)(s) address and phone number published in the school directory.

Required

WHAT PARISH IS YOUR FAMILY REGISTERED TO? *

ST. PATRICK

ST. RICHARD

ST. EDWARD

Other:

A copy of your responses will be emailed to the address you provided.

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