St. Therese of Lisieux Parish Youth Ministry Registration

ST. THERESE OF LISIEUX PARISH YOUTH MINISTRY REGISTRATION JUNIOR HIGH (grades 6-8) and HIGH SCHOOL (grades 9-12)

Student’s Name ______Birthday______

Student’s email:______Grade______

Student’s Cell Phone ______School______

Father’s Name ______Home Phone ______

Mother’s Name ______Family email:______

Mailing

Address ______

Street City State Zip

Father’s Cell Phone______Mother’s Cell Phone______

Please list any special circumstances or allergies which the catechist should know when working with your child on the back of this form. MEDICAL INFORMATION:

DOCTOR: ______

DOCTOR PHONE #: ______

INSURANCE CO.: ______

POLICY #: ______

CARDHOLDER’S NAME: ______

Photograph Permission

Photographs are sometimes taken during faith formation sessions and events. They are displayed publically; e.g., on parish website, in the newspaper, in a brochure, on bulletin boards, facebook, etc. and used to keep the community aware and informed of parish events and activities. Last names will not be posted. If you do not want images taken and used as described, please send a written notice to that effect to the parish Catechetical Leader.

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Signature of parent or legal guardian Date

MY CHILD NEEDS: BAPTISM______CONFIRMATION______1ST EUCHARIST______