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Youth Ministry Permission Slip
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Children
Are you a parishioner of St. Eleanor?
Yes
No
This may only be completed by the parent or legal guardian of the child
Parent / Guardian
Address
Primary Phone
Secondary Phone
E-mail Address
Child's Name
Participant’s Name
Preferred Name
Gender
Male
Female
Date of Birth
School
School Grade
Sixth Grade
Seventh Grade
Eighth Grade
Ninth Grade
Tenth Grade
Eleventh Grade
Twelfth Grade
High School Grad (Class of 2020)
Grade entering in September 2020
Shirt Size
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL
Child E-mail
Child Phone
I give permission for the following
I give permission for the student to receive youth group updates, information, or communication with youth ministers via Text/Remind/Groupme
I give permission for the student to receive youth group updates, information, or communication from the Youth Ministry Staff.
I give permission for the student to participate in virtual youth group sessions using video conferencing services like Zoom.
Unchecked box is NO
Allergies
Medical Conditions / Disabilities
Particular Learning Needs
Please list any medications your child takes regularly
Does your child wear contact lenses?
Yes
No
Are your child’s immunizations up to date?
Yes
No
Family Physician
Doctors Name
Phone
Medical Insurance
Company Name
Group number
Policy number
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Parents / Guardians
Father
Father's Name
Cell Phone
Work Phone
E-mail
Mother
Mother's Name
Cell Phone
Work Phone
E-mail
Is there a special custody arrangement that we need to be aware of?
Yes
No
Marital Status
Married
Divorced
Separated
Remarried
Widowed
Single
Other
With whom does the child live?
Both Parents
Mother
Father
Joint custody - separate house
Mother and Stepfather
Father and Stepmother
Adoptive parents
Foster parents
Other legal guardian
Other
Prefer not to answer
Stepfather's Name
Cell Phone
E-mail
Stepmother's Name
Cell Phone
E-mail
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Emergency Contact Information
Name
If we are unable to contact a parent in the event of an emergency, whom should we contact?
Relationship
Phone
Name 2
Relationship
Phone 2
Terms & Conditions
Youth Ministry Permission Statement:
I hereby give my child permission to participate in all Youth Ministry events and all other trips and programs sponsored by St. Eleanor Parish for the program year beginning April 1, 2020 and ending on August 31, 2021.
In the event my child becomes ill, is injured, or requires medical attention of any kind, and I cannot be reached by telephone, I hereby authorize the adult chaperone to make the necessary decisions concerning emergency treatment. I also give permission for my child to be transported to the nearest medical facility or hospital for treatment.
By signing below, I, as the parent or guardian of the above child(ren) give permission and waive the right to any type of compensation for my child to be photographed or videotaped at any or all activities sponsored by the Youth Ministry Office or Saint Eleanor Parish. Pictures or videos may be used for educational or publicity purposes.
Once again this year we will be utilizing the policy entitled, “Next to Last.” This policy was designed to ensure that at the end of all St. Eleanor Youth Ministry activities, there is never a situation where a single child is left on the premises with only one adult. The “Next to Last” policy is designed to protect both the young people of the parish and the adults who are supervising youth activities. Here is how it will work: At the end of all activities, the young people will be released to their parents, guardians, and carpools. When the “Next to Last” driver arrives to pick up, he or she will be asked to come inside and wait with the remaining child and the other adult chaperone until the last child is picked up. This simple policy will ensure that the children of the parish are in a safe environment, while protecting the adults who help chaperone our parish activities. This policy also will help us to better implement all archdiocesan, parish, and departmental policies.
By typing my
FULL NAME
below, I certify that I am the parent or guardian of the child being registered, and that I agree to the statements made in the Youth Ministry Permission Statement.
FULL NAME
Youth Ministry:
Registration for Saint Eleanor Parish’s Youth Ministry Program is absolutely free. However, if you would like to make a one-time charitable donation to partner with us in the mission of bringing teenagers closer to Christ, please indicate that below. Thank you in advance for any and all generosity, whether in time, talent, or treasure!
Would you like to donate?
Yes
No
Donation Amount
Total Amount
Verification
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