2021 LifeTeen Leadership Conference Registration

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Thank you for registering your teen or LTLC the week of June 27th-July 1st, 2022! This conference is only for rising juniors - just graduated seniors. I look forward to taking them on this retreat! Please fill out this form to complete the registration process. If you have any questions, please contact Lindsay Stokes at Lindsay@SacredHeart-vp.com, or call the Parish Office at (636) 225-5268.

Email *

Participant First Name *

Participant Last Name *

Teen Phone Number (if applicable - used for communication while on the trip) *

Grade *

Rising 11th

Rising 12th

Class of 2022 Graduated Senior

T-Shirt Size (adult size) *

XXL

Emergency Contact Name *

Emergency Contact Phone Number *

Parent Email *

Physician's Name: *

Physician's Phone Number: *

Insurance Company: *

Insurance ID Number: *

Any allergies or medical needs: *

Yes

If yes, what are those allergies?

Is your child on any prescription medication? *

Yes

Is your child responsible for taking his/her own medication?

Yes

Clear selection

If no, what medicine is he/she on and what is the dosage and time given?

Agreements: Communication via text messaging/email: I grant permission for members of the Sacred Heart Youth Ministry Program to notify me and my child about events pertaining to Youth Ministry Program via email and cell phone. *

Yes

Parish/School: I grant permission to use my or my child’s image, name, recording, or academic work in communications that include, but are not limited to, parish bulletin, school newsletter, student newspaper, admission videos, Parish/school website and social media. *

Yes

Archdiocese of St. Louis: I grant permission to use my or my child’s image, name, recording, or academic work in communications that include, but are not limited to, archstl.org, St. Louis Review, Catholic St. Louis magazine, archdiocesan social media, The e-Vangelizer (newsletter published by the Catholic Education Office) and any Publication by agencies administered by the Archdiocese of St. Louis. *

Yes

Sponsoring Organizations: I grant permission to use my or my child’s image, name, recording, or academic work in websites, videos, and publications created by independent foundations and corporations that support Catholic education but are not legally connected to the Archdiocese of St. Louis, including, but not limited to, Today and Tomorrow Educational Foundation, Roman Catholic Foundation of Eastern Missouri, Access Academies, English Tutoring Project, and United Way. *

Yes

Secular media outlets: I grant permission to use my or my child’s image, name, recording, or academic work in secular media communications including, but not limited to, print, radio, TV and internet (Examples: St. Louis Post-Dispatch, KMOX radio, and KSDK-TV). *

Yes

I hereby authorize, through my electronic signature, that my son/daughter can attend and participate in the LifeTeen Leadership Conference the week of June 28th-July 2nd, 2021. I understand that my son/daughter will be offered the opportunity to participate in various activities. It is understood that all possible caution will be taken by those persons in charge to keep everyone safe and to prevent injuries, but the chaperones, the young adult leaders, teens, the sleep house parishioners, and Sacred Heart Valley Park will not be held responsible in the case of an accident or injury. I understand that if my youth behaves in a manner that is deemed inappropriate, is continually disruptive or is found with illegal drugs or alcohol, I will be called immediately to pick up my youth from the activity sight. I hereby authorize any adult chaperone to consent to any medical treatment of the above named youth, which, in the judgement of a recognized medical facility, under the general or special supervision of a licensed physician, may be deemed necessary. Please sign your name: *

Electronic Signature of Parent or Legal Guardian confirming the content of information on this form. *

How are you paying? The total amount is $560 and a deposit of $100 is required to reserve your spot. Note: If finances are an issue, please contact Lindsay Stokes for scholarships. *

To pay online, follow this link: https://sacredheartvp.org/lifeteen-leadership-conference

Check/Cash (sent to SHVP with LTLC in the Memo; Attn: Lindsay Stokes)

Paying online (a 3% processing fee will be added making your deposit $103.00, and your grand total $576.80)

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