<p> ST. THERESE OF LISIEUX PARISH YOUTH MINISTRY REGISTRATION JUNIOR HIGH (grades 6-8) and HIGH SCHOOL (grades 9-12)</p><p>Student’s Name ______Birthday______</p><p>Student’s email:______Grade______</p><p>Student’s Cell Phone ______School______</p><p>Father’s Name ______Home Phone ______</p><p>Mother’s Name ______Family email:______</p><p>Mailing </p><p>Address ______</p><p>Street City State Zip</p><p>Father’s Cell Phone______Mother’s Cell Phone______</p><p>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:</p><p>DOCTOR: ______</p><p>DOCTOR PHONE #: ______</p><p>INSURANCE CO.: ______</p><p>POLICY #: ______</p><p>CARDHOLDER’S NAME: ______</p><p>Photograph Permission</p><p>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.</p><p>______</p><p>Signature of parent or legal guardian Date</p><p>MY CHILD NEEDS: BAPTISM______CONFIRMATION______1ST EUCHARIST______</p>