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2020 Youth Conferences Adult Registration Form
Diocese of Columbus
All registrations made after Noon on February 21 will be considered late and will not be guaranteed a t-shirt at the event.
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Email of Person Completing this Form:
*
Your answer
Name of Parish/School:
*
Choose
Bishop Hartley HS
Bishop Ready HS
Bishop Watterson HS
Blessed Sacrament
Corpus Christi/St. Ladislas/St. Mary
Christ the King/Cristo Rey
Church of the Ascension
Church of the Resurrection
Cristo Rey HS
DeSales HS
Immaculate Conception, Columbus
Immaculate Conception, Kenton
Newark Catholic HS
Our Lady of Lourdes, Ada
Our Lady of Lourdes, Marysville
Our Lady of Peace
Our Lady of Perpetual Help
Our Lady of Victory
Sacred Heart, Coshocton
Saints Alive Catholic Community
Santa Cruz
Scioto Catholic
Seton Parish
St. Andrew
St. Augustine and Gabriel
St. Bernadette
St. Brendan
St. Brigid of Kildare
St. Catharine
St. Cecilia
St. Christopher
St. Colman of Cloyne
St. Dominic
St. Edward the Confessor
St. Francis de Sales, Newark
St. James the Less
St. Joan of Arc
St. John Neumann
St. John XXIII
St. Joseph, Circleville
St. Joseph, Plain City
St. Mary of the Assumption, Lancaster
St. Mary, Chillicothe
St. Mary, Delaware
St. Mary, Marion
St. Mary Church, Groveport
St. Mary Magdalene School
St. Matthew
St. Michael
St. Nicholas, Zanesville
St. Patrick, Columbus
St. Patrick, London
St. Paul the Apostle
St. Pius X
St. Rose
Sts. Simon & Jude
St.Timothy
St. Thomas Aquinas, Zanesville
St. Thomas More Newman Center
St. Thomas the Apostle
St. Vincent de Paul
Tuscarawas Parishes
Other
First Name of Adult Chaperone:
*
Your answer
Last Name of Adult Chaperone:
*
Your answer
Attending
Bosco Bash Middle School Conference
High School Conference
Both Bosco Bash and DCYC
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Gender:
*
Choose
Female
Male
Date of Birth:
*
MM
/
DD
/
YYYY
T-shirt Size
*
Registrations made after 10 AM, Friday, February 21 are not guaranteed a t-shirt. Additional t-shirts will be available on a first-come-first-serve basis for $5 each at the conference
Choose
Late Registration, t-shirt not included.
Mailing Address:
*
Your answer
City:
*
Your answer
State:
*
Your answer
Zip code:
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Your answer
Mobile Phone #:
Your answer
Emergency Contact Name:
*
Your answer
Emergency Contact Phone Number:
*
Your answer
Chronic Conditions, special medical conditions, and/or physical limitations:
*
(e.g. Epilepsy; Diabetes; Paraplegic; etc.)
Your answer
Allergic Reactions:
*
(e.g. Food; Medications; Plants; etc.)
Your answer
Dietary Restrictions:
*
Your answer
Current Medication:
*
The Participant is responsible for providing and taking all medication, prescription or non-prescription, required by the Participant.
Your answer
Medical Insurance:
Your answer
Policy Number:
Your answer
Insurance Member's Name:
Your answer
Insurance Phone #:
Your answer
Family Doctor Name:
Your answer
Family Doctor Phone #:
Your answer
Safe Environment Compliance
*
Current/Valid Background Check
The above listed adult has a Criminal Background Investigation Report on File with the Diocese of Columbus
Safe Environment Compliance
*
Completed Protecting God's Children Training
The above listed adult has completed the Protecting God's Children Training
Permission, Release and Indemnification, and Code of Behavior
*
As the above named chaperone, I have read and agree to all the terms and conditions list in the Permission, Release and Indemnification, and Code of Behavior found here:
https://ec-prod-sites.s3.amazonaws.com/15206/documents/2019/12/DCYC%20Adult%20Release%20and%20Code%20of%20Behavior.pdf
As the Parish/School Group Leader, I understand that I must submit a completed Adult Waiver signed by the adult listed above.
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