St
St. Francis Youth Ministry
Middle School Registration
6th – 8th 2017 - 2018
Está Su familia registrada en esta parroquia? Sí No
Nombre de Joven________________________________ Fecha _________________________
Please Print
Domicilio de casa ______________________________ Teléfono de casa # ________________________
Ciudad, Estado & Código Postal _____________________________________________________________
Correo electrónico (opcional) _________________
Nombre de Mama: ______________ Numero de trabajo de mama ______________ Cellular: ________________
Nombre de Papa: ________________ Numero de trabajo de papa __________________ Celular: _____________
Nombre de Persona para emergencia: __________________ Numero de emergencia # _________________
Mama es Católica? Si No Papa es Católico? Si No
Fecha de Nacimiento de Joven___/___/____ Sexo: Mujer Hombre
Nombre de Escuela: _________________________________ Grado Escolar ________
Yo NO autorizo que se le tomen fotos, videos o cualquier clase de grabacion a mi hijo(a)s.
Personas autorizadas para levantar al Joven: ___________________________________________________
Firma del Padre/Guardian es requerida _____________________________________________________
Office use:
Date entered _________ On Remind List _________ YM or CM name____________________
St. Francis Youth Ministry
Middle School Registration
6th – 8th 2017 - 2018
Is your family registered in this Parish? Yes No
Youth Name________________________________ Today’s Date ___________________________
Please Print
Home Address __________________________________ Home Phone # _____________________
City, State & Zip___________________________________________________________________
E-mail (optional) __________________________
Mother’s Name: ___________________ Mom’s work phone # _________________ Cell: _____________
Father’s Name: ___________________ Dad’s work Phone # __________________ Cell: _____________
Emergency Contact Name: ___________________________ Emergency Phone # ____________________
Mom is Catholic? Yes No Dad is Catholic? Yes No
Youth Birthdate___/___/____ Sex: Female Male
School Name: ____________________________ School Grade in the fall ________
By checking this box, I DO NOT authorize any photos, videotapes or recordings of my child. My youth will not participate in photo sessions or recordings.
Name of Person(s) Authorized to pick up Youth: ___________________________________________
Signature of Parent/Guardian _______________________________________________________
Print full name of Parent/Guardian ______________________________________________________
Office use:
Date entered _________ On Remind List _________ YM or CM name____________________
Photo Release Form
I hereby grant the St. Francis of Assisi Catholic Church permission to use my picture(s) in any and all of its publications, including website entries, without payment or any other consideration.
I understand and agree that these materials will become the property of the St. Francis of Assisi Catholic Church and will not be returned.
I hereby irrevocably authorize the St. Francis of Assisi Catholic Church to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing the St. Francis of Assisi Catholic Church programs or for any other lawful purpose.
In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph.
I hereby hold harmless and release and forever discharge the St. Francis of Assisi Catholic Church from all claims, demands, and causes of action which, I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
I am 18 years of age and am competent to contract in my own name. I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.
___________________________________ _____________________
(Signature) (Date)
__________________________________ _____________________
(Printed Name) (Date)
If the person signing is under age 18, there must be consent by a parent or guardian, as follows:
I hereby certify that I am the parent or guardian of ________________________, named above, and do hereby give my consent without reservation to the foregoing on behalf of this person.
____________________________________ ______________________
(Parent/Guardian’s Signature) (Date)
(Parent/Guardian’s Printed Name)
Parent/Student Education on Safe Environment
St. Francis of Assisi will present throughout the year the Touching Safety Program, a sexual abuse program to our students. The creators of the Protecting God’s Children Program developed the Touching Safety program. This program is provided to us by the Diocese of San Bernardino, and is part of our ongoing effort to help create and maintain a safe environment for children and youth to protect all children and youth from sexual abuse.
As a parent you have the right to choose whether your son or daughter participates in the parish presentations of the sessions or you as a parent presents this information at home. Please complete the form at the bottom of this page.
Please sign only one:
St. Francis HAS my permission to present the “Virtus” program, to my child whose name is: ____________________________________
St Francis DOES NOT have my permission to present the “Virtus” program, to my child whose name is:____________________________________
Parent’s name (printed):________________________________________
Parent’s signature:_____________________________________________
Date:____________________________________________
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