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Youth Group Yearly Form

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  - Young Adult Ministry Inquiry

Youth Group 2025-2026 Release Form
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- Number of Children REQUIRED Please fill out this field.
  
  Child Info 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Any allergies, medications, or additional information REQUIRED Please fill out this field. Please enter valid data.
  
  School REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Child Info 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Any allergies, medications, or additional information REQUIRED Please fill out this field. Please enter valid data.
  
  School REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Child Info 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Any allergies, medications, or additional information REQUIRED Please fill out this field. Please enter valid data.
  
  School REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Child Info 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Any allergies, medications, or additional information REQUIRED Please fill out this field. Please enter valid data.
  
  School REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter valid data.
- Parent Information
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Street Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Emergency Contact Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Email REQUIRED Please fill out this field. Please enter an email address.
- MEDICAL RELEASE
  
  As a parent/guardian, I do hereby authorize the treatment by a qualified and licensed physician of any condition which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me. I further authorize the person who presents the minor to sign the Acknowledgement of Receipt of Notice Privacy Rights that may be presented by the physician or health care facility. This authorization is complete and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician.
- I Agree Please select this field.
- Family Physician Data
- Physician/Office REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Health Insurance Data
- Company REQUIRED Please fill out this field. Please enter valid data.
- Policy Holder REQUIRED Please fill out this field. Please enter valid data.
- Group # REQUIRED Please fill out this field. Please enter valid data.
- Policy # REQUIRED Please fill out this field. Please enter valid data.
- PHOTO RELEASE
- I hereby grant permission to St. Catherine of Siena Parish to publish my child's photo, or video image in connection with a display, feature story or other publication as deemed appropriate by the parish. This photo may be used in connection with: parish bulletin boards, publicity materials, school website or parish website and parish's social media.
  
  We respect your right to privacy, if you do not want your child photographs used please check below. Please realize that your child will be asked to step out of a group photo.
- Can your child's picture be taken? REQUIRED Yes No Please fill out this field.
- By entering into and/or signing this document, the signatory/signatories agree to conduct its/their dealings via electronic means. The signatory agrees that allowing dealings via electronic means will facilitate these dealings. The signatory has the option to opt to sign things in a paper format
- Parent/ Guardian Initials REQUIRED Please fill out this field. Please enter valid data.
- Please list anyone NOT allowed to pick up Child Please enter valid data.
- Parent/Guardian electronic signature REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.
Submit

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