Steubenville South Conference

Teen's Name REQUIRED Please fill out this field. Please enter valid data.

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.

Teen cell number REQUIRED Please fill out this field. Please enter valid data.

Gender REQUIRED Male Female Please fill out this field.

Current grade REQUIRED 9th 10th 11th 12th Please fill out this field.

Date of birth REQUIRED Please fill out this field. Please enter valid data.

Roommate request Please enter valid data.

T-shirt size S M L XL

Parent Name REQUIRED Please fill out this field. Please enter valid data.

Parent cell REQUIRED Please fill out this field. Please enter valid data.

Emergency contact REQUIRED Please fill out this field. Please enter valid data.

Emergency contact cell REQUIRED Please fill out this field. Please enter valid data.

Allergies/Medical conditions Please enter valid data.

Other medical/mental conditions you want us to be aware of

Physical limitations Please enter valid data.

Immunizations up to date? REQUIRED Yes No Please fill out this field.

Current medications Please enter valid data.

Medicine consent I hereby Do Not grant permission for medication of any type , whether prescription or nonprescription may be administered by my child unless the situation is life threatening and emergency treatment is required I hereby Grant Permission for nonprescription medication (such as Tylenol, throat lozenges, cough syrup, etc) to be given to my child if deemed advisable. I understand that Aspirin will not be given to my son/daughter.

Insurance company Please enter valid data.

Insurance ID Please enter valid data.

Insurance Group number Please enter valid data.

Medical Consent/Liability Waiver
In the event of an emergency, I hereby give permission to the staff of Mary Queen Catholic Church to seek emergency medical transport or treatment for my child(ren) named above. I wish to be advised before further care is given by the hospital or doctor and I understand that all financial obligations are my responsibility. If I cannot be reached please contact the person listed above.

In consideration of my child's participation in Faith Formation, I agree on behalf of myself, my child(ren) named above, and our heirs, successors, and assigns, to indemnify, hold harmless and defend the Daniel Cardinal DiNardo, Archdiocese of Galveston-Houston, Mary Queen Catholic church, its pastor or any representative of Faith Formation or Yourth Ministry (collectively the "indemnitees") from any and all injuries, losses or claims arising out of my child's participation in the program. I further agree that if anyone on my child's behalf makes a claim against the indemnitees, I will indemnify, save, and hold harmless each of the indemnitees from any litigation, expenses, attorney fees, loss, liability, damage or cost which may incur as a result of such claim.

Medical Consent/Liability Waiver REQUIRED Please fill out this field.

Video/Photography Consent
As parent/guardian, I understand that promotional pictures and videos (individual and group) may be taken during Faith Formation Classes and/or Youth Ministry Activities. I give permission for my child(ren)'s (named above) pictures to be used for church promotional materials such as newsletters, web pages, social media, calendars, power point presentations, or videos to promote or highlight these classes or activities.

Video/Photography Consent REQUIRED Please fill out this field.

Parent signature and date REQUIRED Please fill out this field. Please enter valid data.

Participant signature and date REQUIRED Please fill out this field. Please enter valid data.

Payment options REQUIRED Nonrefundable Deposit - $80.00 Payment in full - $355.00 Other – I will need scholarship assistance due to financial hardship (indicate amount below). Please fill out this field.

I can pay $_______ for a non-refundable deposit to save my teen’s spot Please enter valid data.

There are a limited number of scholarships available and will be given on a first come first serve basis. Up to one camp scholarship will be considered per teen per year.

Payment

Scholarship option $ Please enter a positive decimal.