Family InformationFamily Last Name(Required) Last Address Street Address City State / Province / Region ZIP / Postal Code Mother's Name First Last (if different) Mother's Phone NumberMother's Email Address Father's Name First Last (if different) Father's Phone NumberFather's Email Address Who can we contact in the case of an emergency?We highly recommend listing a contact that is not the child’s parent(s). We will always attempt to contact the parent(s) before the emergency contact.Emergency Contact(Required) First Last Relationship to Student(Required)GuardianAuntChild Care ProviderCousinFamily FriendFatherGodparentGrandfatherGrandmotherHost FamilyMotherSiblingStep-FatherStep-MotherUncleEmergency Contact Phone Number(Required)Student InformationStudent Name(Required) First Last Student Date of Birth Month Day Year AgePlease enter a number greater than or equal to 10.Gender Male Female Name of School that Student AttendsSacraments Received Baptism Reconcilitation First Communion Confirmation Select AllAllergies or Special Needs?(Required) Yes No Allergies/Special Needs Details(Required)Do you have a 2nd student (6th-12th) participating in the youth ministry program?(Required) Yes No Student Name (2nd student)(Required) First Last Student Date of Birth Month Day Year AgePlease enter a number greater than or equal to 10.Gender Male Female Name of School that Student AttendsSacraments Received Baptism Reconcilitation First Communion Confirmation Select AllAllergies or Special Needs? (2nd student)(Required) Yes No Allergies/Special Needs Details (2nd student)(Required)Do you have a 3rd student (6th-12th) participating in the youth ministry program?(Required) Yes No Student Name(Required) First Last Student Date of Birth Month Day Year AgePlease enter a number greater than or equal to 10.Gender(Required) Male Female Name of School that Student AttendsSacraments Received Baptism Reconcilitation First Communion Confirmation Select AllAllergies or Special Needs? (3rd student)(Required) Yes No Allergies/Special Needs Details (3rd student)(Required)ConsentMedical Release(Required) I agree to the Medical Policy.I certify that I am the custodial parent/legal guardian of the minor children listed above. In the event of sickness or medical emergency where I am not present and cannot be reached, I request that my child(ren) receive any medical attention or treatment deemed necessary by the Staff or Volunteer leaders of St. Anthony of Padua Catholic Community. The above-named child(ren) has my permission to travel for medical treatment in a privately-owned vehicle or ambulance. In addition, I do hereby authorize treatment by a qualified and license Medical Doctor in an emergency which, in the opinion of the attending physician, may endanger the child’s life, cause disfigurement, physical impairment, or undue discomfort if delayed.Signature(Required)Consent to Direct Student Communication I give my consent to Director of Youth Ministry, Zaven Mouradian to directly communicate with my student(s).I (Parent/Legal Guardian) give consent for the Director of Youth Ministry, Zaven Mouradian, to contact my children listed on this form between the ages of 6th-12th grade via text message, calling, and email.SignaturePhoto/Media Release I agree to Photo/Media ReleaseI understand that through their participation in this program, my child(ren) listed on this registration may be photographed for use in the promotion of parish & diocesan programs. As parent/guardian, I give permission for my child(ren) to be photographed during this program.Signature
