Youth Ministry Registration

386-672-5272

600 S. Nova Road
Ormond Beach, FL 32174

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Name:

What Grade is the Child/Teen in?

School of Attendance

Date of Birth

Father/Guardian's Full Name

Mother/Guardian's Full Name

Email:

Email 2

Emergency contact Full Name

Emergency Contact Phone Number

Medical Matters: I hereby warrant to the best of my knowledge, all the information provided is true and correct and I assume all responsibility for the health of my child. I understand it is my responsibility to update the Medical information and Consent Form if there are any changes to my child's health (Please, initial)

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital/clinic for emergency medical or surgical treatment (Please, initial)

Family Doctor

Family Doctor's phone number

New Field:

Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency, are as follows:

Free Text

Medical Conditions Information: (Reasonable steps will be taken to keep this information confidential, but it will be shared with Diocesan personnel and others, as warranted.)

My son/daughter is allergic to the following medications: (Please list below)

My son/daughter has had an episode of the following or has been diagnosed with seizures, asthma, diabetic

Seizures

Asthma

Diabetic

My son/daughter has had allergic reactions to the following (foods, dyes, latex, etc.)

My son/daughter has had a medical surgery within the last six months and still under doctor's care? click on the box to type in the answer)

My son/daughter has a medically prescribed diet (please explain)

My son/daughter has the following physical limitations: (list the limitations if any)

Immunizations current and up to date?

Yes

Date of last tetanus/diphtheria immunization?

You should also be aware of these special medical conditions of my child:

Insurance information: Do you carry medical insurance for your child at this time?

Insurance carrier

Name of insured

Insurance Policy number

Free Text

In the event the participant does not have insurance, payment in full for medical care becomes the responsibility of the participant's parent/guardian.

New Field:

Free Text

Photography and Image Assignment, Waiver, and Release

I, (you will type your name below) for valuable consideration received and for being allowed access to Diocesan property, activities, or events, expressly assign to Prince of Peace and the Diocese of Orlando, and to all of their current, former, and future agents and related entities (collectively, "the Diocese"), all rights, title and interest in, and to, the use of my and my child/ward's image of likeness, including, but not limited to all videotape recordings, photographs, or audio recordings of, or made by, me and/or my child/ward on Diocesan property, during a Diocesan-sponsored event, or for any other Diocesan purpose ("the Property"). The Diocese shall have, without my consent, the right to assign its rights in the Property, in whole or in part, to any entity, parish, or school within the Diocese of Orlando. I hereby irrevocably grant the Diocese perpetually and exclusively, the right to use and incorporate (alone or together with other materials), in whole or in part, the Property, in any Diocesan publication, news release, or for any other purpose. Further, I hereby authorize the reproduction, sale, lease, copyright, exhibition, broadcast and/or distribution of the Property without limitation for nay purpose whatsoever, and I further waive all rights to any compensation for my and /or my child/ward's appearance of participation in the Property. I understand and have been advised that photographs or videotape of participants may be used in publications, websites or other materials produced from time to time by the Office of Youth and Young Adult Ministry and/or the Diocese. Particpants' names would not be identified, however, without specific written consent. I further understand that the Diocese has no control over the use of photographs or film taken by media that my be covering the event in which my child(ren)ward(s) participate(s). I hereby waive any claims against and release the Diocese, its current, former, and future religious, emplyoees, volunteers, agents, and successors and assigns from and against any and all claims, demands, actions, causes of actions suits, costs, expenses, liabilities, and damages whatsoever that I and/or my child/ward may have against the Diocese in connection with the Property or the use of the Property. This release shall not obligate the Diocese to use the Property or to use any of the rights granted hereunder, or to exhibit, distribute, or exploit the Property. I acknowledge that the Diocese cannot control all photographic access to its properties, and that my child/ward's name may be printed with photos/images in various publications, including non-Diocesan publications I represent that I am eighteen years of age or older, and that I have read and understand the terms of this Assignment, Waiver, and Release (by typing my full name and date below)

Free Text

Consent Form for Electronic Communication with Minors: In order to ensure utmost transparency and parental involvement, the Diocese of Orlando has created this consent form so that parents and guardians may select how ministry leaders communicate electronically with minors. Any and all digital networking and communication Including but not limited to, email, texting. Facebook, Twitter, other Social Networking sites, etc, with parish youth/school/organization will be ministry related and NOT personal in nature, restricted to matter concerning classes, youth ministry events, parish events, school events, athletic/event schedule or registration forms. This form will be filed in a confidential folder for parish/school/organizational use only. The person(s) being authorized to communicate with the minor child is In compliance with the Diocese of Orlando Safe Environment Policy with this parish/school.

Name of Parent/Guardian:

Name of Minor Child/Teen:

Name of Ministry Leader:

Name of Parish/School:

Approved Parent Communication Methods (Check all that apply):

Home Phone

Cell Phone (phone/text)

Social Media Account

Other (Please Explain Below)

Other. (please explain)

Approved Child/Teen Communication Methods (Check all that apply):

Home Phone

Cell Phone (Phone/text)

Social Media Accounts

Remind

Other (please explain below)

You may not contact my child/teen directly,

Other. (please explain)

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600 S. Nova Road
Ormond Beach, FL 32174

386-672-5272

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386-672-5272

600 S. Nova RoadOrmond Beach, FL 32174