High School Youth Ministry and/or Confirmation 2023-2024 Registration High School Youth Ministry and/or Confirmation 2023-2024 Student InformationName:* First Last Email: Enter Email Confirm Email Cell phone:*Birthdate:* Grade level:* Freshman (Grade 9- Confirmation Year 1) Sophomore (Grade 10-Confirmation Year 2) Junior (Grade 11) Senior (Grade 12) T-Shirt Size:* X-Small Small Medium Large X-Large 2XL 3XL Home address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code We will continue to meet in small group/discipleship groups. Please name 1-2 teens that you would like to have in your group. If you have any special requests/information that would be good for me to know, please add that here.Please give your SUNDAY and WEDNESDAY (if applicable) availability here for discipleship groups. (No earlier than 12N on Sundays and No earlier than 4P on Wednesdays)Family InformationParent/Guardian 1:* First Last Relationship to Child:* Cell Phone:*Preferred email:* Parent/Guardian 2: First Last Relationship to Child: Cell Phone:Preferred Email: Enter Email Confirm Email Is your family registered at Saint James Parish?* Yes No If not, where do you normally attend church? Emergency ContactEmergency Contact (not parent):* Phone:*Medical Information & Medical ReleaseMedical Information — Insurance Co. Policy #: Primary Care Physician: Allergies (medication or food) Medical Release: I agree to the Medical Release and indicate my consent by my electronic signature below.As the parent or legal guardian of the above named child, I hereby authorize St. James to permit any necessary examination, anesthetic, medical diagnosis, surgery or treatment, and/or hospital care to be rendered to said child under the general or special supervision and on the advice of any physician licensed to practice medicine in the state of Kentucky. SignatureDate Month Day Year Publication Permission FormPublication Permission Form for Photographing, Printing, and Publishing: I agree to the publication permission policy and indicate my consent by my electronic signature below.I, the undersigned, give permission to the director of religious education and/or the youth minister of St. James Church to take and publish photographs of my child for use/publication in parish bulletins, parish bulletin boards, parish/diocesan newsletters, parish/diocesan internet websites, and the diocesan newspaper.Signature:Date Month Day Year Year- Round Permission FormYear-Round Permission Form* I agree to the permission policy and indicate my consent by my electronic signature below.I (We), parent(s)/guardian(s) request that my child be allowed to participate in the activities and events scheduled for the 2023-2024 youth ministry calendar, including summer 2024. I (WE) further give my (our) permission for our child to ride in any vehicle designated by the adult in whose care my (our) child has been entrusted while participating in the above activities. In consideration of permitting my (our) child to attend and/or participate, I (we) do hereby, for myself (ourselves) and my (our) child (children) waive and release any and all claims that I might have against Olivia Dvorjak, Saint James Church and any designated driver of a van, bus, car or vehicle, for any and all injuries or losses suffered by said child (children) while engaged in the above activities. In case of any medical emergency, I understand that every effort will be made to contact the parents or guardians of the child participating in the Youth Ministry Programming of the parish. In the event that I cannot be reached, I hereby give permission to the physician selected by the Youth Ministry Coordinator to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child, as named herein.Signature:Date Month Day Year Fees & PaymentStudent fees help to offset costs of materials and resources used during the program. Please add a “1” to the appropriate field below.Year I Confirmation Fee — Grade 9 Quantity Price: $150.00 Quantity Retreats, books, resources, shirt, and snacks/food for Confirmation year 1 and for the retreats for year 1 and 2. // If these fees present a financial burden to your family, please select “Other” and contact Olivia Dvorjak.Year 2/Youth Ministry Fee–Grades 10, 11, 12 Quantity Price: $75.00 Quantity Books, food/snacks, resources, shirt // If these fees present a financial burden to your family, please select “Other” and contact Olivia Dvorjak.Total $0.00 Method of payment:* Credit card Check (I will bring to the Parish Office) Credit CardCard Details Cardholder Name Δ Click to share on Facebook (Opens in new window)Click to share on Twitter (Opens in new window)Click to share on LinkedIn (Opens in new window)Click to share on Pinterest (Opens in new window)Click to print (Opens in new window)MoreClick to share on Tumblr (Opens in new window)Click to share on Pocket (Opens in new window)Click to share on Reddit (Opens in new window)