Youth Ministry

Family Information

Parent Name *

First

Last

Registered at St. Therese? *

Yes
No

Phone *

Email *

Address *

Assistance is confidentially available for anyone who expresses financial hardship. Would you like more information on these scholarships? *

Would you like to be added to the Facebook group?

Children Information

Please enter the information below for each child you are registering.

How many children are you registering? *

Information for Child #1

Name

Birthdate

Gender

Grade

School attending

Sacraments Received

Baptism
Reconciliation
Eucharist
Confirmation

Specific Medical Information Allergic Reactions -Medications, food, plant, insects etc; Does your child have a medically prescribed diet ; You should be aware of these special medical conditions of my child:

Baptism information (Date, Church, City, State)

Information for Child #2

Name

Birthdate

Gender

Grade

School attending

Sacraments

Baptism
Reconciliation
Eucharist
Confirmation

Specific Medical Information Allergic Reactions -Medications, food, plant, insects etc; Does your child have a medically prescribed diet ; You should be aware of these special medical conditions of my child:

Baptism information (Date, Church, City, State)

Information for Child #3

Name

Birthdate

Gender

Grade

School Attending

Sacraments Received

Baptism
Eucharist
Reconciliation
Confirmation

Specific Medical Information Allergic Reactions -Medications, food, plant, insects etc; Does your child have a medically prescribed diet ; You should be aware of these special medical conditions of my child:

Baptism information (Date, Church, City, State)

For additional children, please provide the above information for your remaining children:

Parent/Gaurdian Consent Form and Liability Waiver for Medical Treatment

I grant permission for my child(ren) to participate in the Faith Formation classes. These activities will take place under the guidance and direction of parish employees and/or volunteers from St. Therese Catholic Church. As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor ('Participant'). I agree on behalf of myself, my child(ren), or our heirs, successors , and assigns, to hold harmless and defend St. Therese Church, its officers, directors, employees, and agents, and the Diocese of Richmond, its employees and agents, chaparones or representatives associated with the event, from any claim arising from or in connections with my child attending the event or in connections with any illness or injury, (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors and agents, and the Diocese of Richmond, its employees and agents and chaparones, or actions brought against them as a result of such injury or damage, unless such claims arises from negligence of the parish/diocese. *

I grant this permission

Medical Matters: I hereby warrant that to the best of my knowledge, my child(ren) is/are in good health, and I assume all responsibility for the health of my child. Emergency Medical Treatment: in the event of an emergency, I hereby give permission to transport my child(ren) 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 an emergency, if you are unable to reach me at given numbers contact: *

First

Last

Relationship

Phone

Family Physician

Phone

Health Care Provider

Policy #

Picture Release I, the undersigned parent or legal guardian, hereby grant permission for all photos taken of my child(ren) at St. Therese Catholic Church Faith Formation program/parish to be used for either publicity, advertising or on webpage for the program or parish.

Sign up for Faith Formation or Confirmation using the form below:</font color>

Family Information

Children Information

Information for Child #1

Information for Child #2

Information for Child #3

Parent/Gaurdian Consent Form and Liability Waiver for Medical Treatment

Resources for Teens