Youth Ministry Permission Slip

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

Grade entering in September 2021

Shirt Size

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

Page Break

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

With whom does the child live?

Stepfather's Name

Cell Phone

E-mail

Stepmother's Name

Cell Phone

E-mail

Page Break

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 June 1, 2021 and ending on August 31, 2022.

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