LIFE TEEN

High School Ministry

Sessions

Sundays, 12 pm-2 pm

Tuition

FREE

Please complete the information for each of the youth who will be attending LIFE TEEN.

Family Contact Information
Is the Family registered at St.Pius X Church?
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FAMILY LAST NAME
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Address
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Primary Phone --
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FATHER'S INFORMATION
Name:
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Father is:
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Religion:
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E-mail:
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Cell phone #: --
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MOTHER'S INFORMATION
MAIDEN Name:
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Mother is:
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Religion:
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E-mail:
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Cell phone #: --
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Emergency Contact
Name:
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Person to be reached during Religious Ed
Relationship to child:
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Emergency Phone Number --
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Family Background
Parents are:
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Children live with:
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Family Ethnicity
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If other:
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Youth 1
New registration of students requires Baptismal Certificate if Baptism was not done at St. Pius X.
The child is a:
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Child's Name
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Birth Date //
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Gender
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Grade 2018-2019
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School 2018-2019
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Sacraments Completed
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Church, City, State, Country of Child's Baptism
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Special Requests
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Medical Condition or Allergies
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Youth 2
New registration of students requires Baptismal Certificate if Baptism was not done at St. Pius X.
The child is a:
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Child's Name
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Birth Date //
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Gender
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Grade 2018-2019
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School 2018-2019
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Sacraments Completed
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Church, City, State, Country of Child's Baptism
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Special Requests
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Medical Condition or Allergies
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Youth 3
New registration of students requires Baptismal Certificate if Baptism was not done at St. Pius X.
The child is a:
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Child's Name
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Birth Date //
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Gender
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Grade 2018-2019
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School 2018-2019
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Sacraments Completed
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Church, City, State, Country of Child's Baptism
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Special Requests
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Medical Condition or Allergies
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Permission/Liability & Medical Release
Use of Pictures and/or Video I give permission for pictures and/or video of my child (named above) engaged in activities related to the parish or Diocesan event to have their pictures posted in St. Pius X the Diocese of Richmond publications or websites. Names of participants will not be used without expressed permission from the parent or guardian. If no box is checked below, the Diocese of Richmond assumes you give permission.
Use of Pictures and/or Video
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If no box is checked the Diocese of Richmond and St.Pius X assumes you give permission.
Liability and Medical Release As parent and/or legal guardian I remain legally responsible for any personal actions taken by the above named minor. I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St. Pius X and the Catholic Diocese of Richmond, its employees and agents, chaperons, or representatives associated with this event from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the Diocese, its employees and agents and chaperons, or representatives associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the Diocese. I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. In the event of any emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers I give permission for the noted emergency contact to be notified. I will not hold St. Pius X and the Diocese of Richmond responsible for authorizing any medical treatment beyond necessary transportation to the hospital.
Parent or Legal Guardian
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Name of the Person completing this form
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Parent Signature
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Once you submit this form, registration is not complete until payment is received in the parish office. Checks should be made to "St.Pius X Church" and specify RE registration and Family last name on the memo line.