2022-2023 YOUTH MINISTRY REGISTRATION Please enable JavaScript in your browser to complete this form.1234Please specify your selection/ Por favor elije una seccion: *Middle School Student/ grados 6, 7, 8High School Student/ grados 9, 10, 11, 12Family (two or more students)/ Familias con dos o mas estudiantesSTUDENT INFORMATIONIn an effort to offset the cost of snacks, meals, youth ministry t-shirt and materials for youth events during the year, St. Leo’s does assess an Activity Fee. However, we will not and have never turned a youth away if cost is an issue. We would ask that you contribute what you can, if you need assistance, please do not hesitate to contact Katherin Aguilar, Director of Youth Ministry. The activity fee structure also takes into account family with multiple participating children: Middle School: $60/youth High School: $85/youth Family (two or more students): $120/family Please fill out all required fields marked with an asterisk (*).Student Name / Nombre del estudiante *FirstMiddleLastAddress / Direccion *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone / Telefono de Casa *Student Cell Phone / Telefono del estudianteStudent Email / Correo electronico del estudiante *Birthday / Fecha de nacimiento *Current Grade / Grado actual *6th7th8th9th10th11th12thSchool / Escuela *T-Shirt Size (Adult Size) / Talla de camiseta *Small (S)Medium (M)Large (L)Extra Large (XL)Double Extra Large (XXL)High School Students Only / Estudiantes de la segundariaDo you need Sacraments? RCIT is a one-year program. Click here if needed, and we will send you more information.¿Necesitas los sacramentos? RCIT es un programa de un año. Marque esta casilla y le enviaremos más información.Teen Lectors are needed for the last Sunday. 5pm Mass of each month, September-May. Check here if you'd like to be added to the list?Se necesitan lectores adolescentes para la misa de las 5 pm el último domingo de cada mes. Marque aquí si desea ser agregado a la lista.Add second students information? / ¿Agregar información de segundo estudiante? *YesNoStudent Name / Nombre del estudiante *FirstMiddleLastStudent Email / Correo electronico *Birthday / Fecha de nacimiento *Current Grade / Grado actual *6th7th8th9th10th11th12thSchool / Escuela *T-Shirt Size (Adult Size) / Talla de camiseta *Small (S)Medium (M)Large (L)Extra Large (XL)Double Extra Large (XXL)High School Students Only / Estudiantes de la segundariaDo you need Sacraments? OCIT is a one-year program. Click here if needed, and we will send you more information.¿Necesitas los sacramentos? OCIT es un programa de un año. Marque esta casilla y le enviaremos más información.Teen Lectors are needed for the last Sunday. 5pm Mass of each month, September-May. Check here if you'd like to be added to the list?Se necesitan lectores adolescentes para la misa de las 5 pm el último domingo de cada mes. Marque aquí si desea ser agregado a la lista.Add third students information? / ¿Agregar la información del tercer estudiante? *YesNoStudent Name / Nombre del estudiante *FirstMiddleLastStudent Email / Correo electronico *Birthday / fecha de nacimiento *Current Grade / Grado actual *6th7th8th9th10th11th12thSchool / Escuela *T-Shirt Size (Adult Size) / Talla de camiseta *Small (S)Medium (M)Large (L)Extra Large (XL)Double Extra Large (XXL)High School Students Only / Estudiantes de la segundariaDo you need Sacraments? OCIT is a one-year program. Click here if needed, and we will send you more information.¿Necesitas los sacramentos? OCIT es un programa de un año. Marque esta casilla y le enviaremos más información.Teen Lectors are needed for the last Sunday. 5pm Mass of each month, September-May. Check here if you'd like to be added to the list?Se necesitan lectores adolescentesAdd fourth students information? *YesNoStudent Name *FirstMiddleLastStudent Email *Birthday *Current Grade *6th7th8th9th10th11th12thSchool *T-Shirt Size (Adult Size) *Small (S)Medium (M)Large (L)Extra Large (XL)Double Extra Large (XXL)High School Students Only:Do you need Sacraments? RCIT is a one-year program. Click here if needed, and we will send you more information.Teen Lectors are needed for the last Sunday. 5pm Mass of each month, September-May. Check here if you'd like to be added to the list?NextPARENT/GUARDIAN INFORMATIONParent or Guardian Name / Nombre del Padre o Guardian *FirstLastParent or Guardian Email/ Correo Electronico del Padre o Guardian *Parent or Guardian Cell Phone/ Numero de telefono del Padre o Guardian *Parent or Guardian Work Phone/ Telefono del trabajo del Padre o GuardianRelationship to teen? / Relacion con el joven?MotherFatherOtherPlease specify your relationship with the student or teen/ Por favor especifique la relacion con el estudiante/joven *RELEASE FORMSSAFETY As the participant, I agree to follow all procedures, safety precautions, and rules and regulations set forth by the Diocese and the Parish.Print Full Name/ Nombre completo del Padre *PARENTAL PERMISSION AND LIABILITY RELEASE As parent/legal guardian of the participant names above, I give my permission to participate fully in St. Leo the Great Youth Ministry Meetings/Events from August 22, 2021 to September 5, 2022. I agree to indemnify and hereby release the Most Reverend Michael F. Burbidge Bishop of the Catholic Diocese of Arlington and his successors in office, as well as the Catholic Diocese of Arlington and all Diocesan clergy, employees, volunteers, and participating parishes and schools from any and all liability, claims, demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned of the participant resulting from said participant’s involvement in the above mentioned event (including transportation to and from the event). Furthermore, I on behalf of the participant hereby assume all risk of personal injury, sickness, death, damage, and expenses resulting from said participant’s involvement in the above described event.Print Full Name/ Nombre completo *INFORMED CONSENT TO MEDICAL TREATMENT I request that in my absence the above-named minor be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor. I assume full responsibility for all costs of such treatment. Further, should it be necessary for the participant to return home due to medical, disciplinary, or other reasons, I do hereby assume responsibility for the participant’s transportation home and any costs related thereto.Print Full Name *PHOTO, PRESS, AUDIO, AND ELECTRONIC MEDIA RELEASE I authorize the Catholic Diocese of Arlington, its parishes, its schools and/or the Arlington Catholic Herald to use and publish my child’s photograph, video and/or audio recording along with their name identifying them for educational, news stories, illustration and/or marketing purposes.Print Full Name *NextMEDICAL INFORMATION/INFORMACION MEDICA(P.S. ALL INFORMATION IS KEPT PRIVATE)MEDICATIONS Please list any prescription or doctor prescribed over the counter medications your child is usingDrug Name/Nombre de la medicinaDosage/DosisDrug Name/Nombre de la medicinaDosage/DosisIn case there are additional drugs, please mention the drug name and its dosage below:/ En caso que haya medicina adicional, por favor mencione el nombre de la medicina y sus dosis abajo:ALLERGIESEnvironmental (i.e. pollen, dust)/ Ambiente( ejemplo: polen, polvo)Any Medications/Alguna medicinaFood/ComidaDoes your child have an EPI-pen? / Su hijo tiene un autoinyector de Epinefrina?YesNoDo they know how to administer it to themselves?/ Sabe como administrarlo el mismo?YesNoHISTORYMedical History (be specific) / Historial Medico ( sea especifico)Mental Health Information (be specific)/ Informacion de salud mental ( sea especifico)Physician and Medical InsurancePrimary Healthcare Provider / Proveedor primario del Cuidado de la saludPhone/ Numero de TelefonoInsurance Company / Compañia de SeguroPolicy Number/ Numero de PolizaEmergency ContactName/Nombre *FirstLastRelationship/ RelacionPhone/Numero de TelefonoNextREGISTRATION FEEAs a reminder, in an effort to offset the cost of snacks, meals, youth ministry t-shirt and materials for youth events during the year, St. Leo’s does assess an Activity Fee. However, we will not and have never turned a youth away if cost is an issue. We would ask that you contribute what you can, if you need assistance, please do not hesitate to contact Katherine Aguilar, Director of Youth Ministry. The activity fee structure also takes into account family with multiple participating children: Middle School: $60/youth High School: $85/youth Family (two or more students): $120/family (Our online payment system is 100% safe and secure. We do NOT store any of your credit card information. We respect your privacy!)Would you like to save time & pay the registration fee online right now? *Yes, I'll pay right now via credit card.No, I'll give you a check. (Please choose if you need to defer payment at this time)Total:Price: $ 60.00Total:Price: $ 85.00Total:Price: $ 120.00Credit Card *Card NumberSecurity CodeName on CardExpirationMM123456789101112/YY2324252627282930313233BILLING DETAILS Our online payment system is 100% safe and secure. We do NOT store any of your credit card information. We respect your privacy!Credit Card *CardName on CardSubmit