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Saint Rose Youth Group Registration

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  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Which Youth Group? REQUIRED Middle School High School Please fill out this field.
  
  Street Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  Email Address REQUIRED Please fill out this field. Please enter valid data.
  
  MEDICAL RELEASE
  I further authorize the person who presents the minor to sign the Acknowledgement of Receipt of Notice Privacy Rights that may be presented by the physician or health care facility. This authorization is complete and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician.
  
  Medical Release Agreement REQUIRED I agree Please fill out this field.
  
  Family Physician Data (Physician/Office) REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  Zip Code REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field. Please enter valid data.
  
  Health Insurance Company REQUIRED Please fill out this field. Please enter valid data.
  
  Health Insurance Group # REQUIRED Please fill out this field. Please enter valid data.
  
  Health Insurance Policy # REQUIRED Please fill out this field. Please enter valid data.
  
  Contact REQUIRED Please fill out this field. Please enter valid data.
  
  Photo Release
  I hereby grant permission to St. Rose parish to publish my child's photo or video image in connection with a display, feature story or other publication as deemed appropriate by the parish. This photo may be used in connection with: parish bulletin boards, publicity materials, school website or parish website and parish's social media.
  
  We respect your rights to privacy. If you do not want your child photographs used please check below. Please realize that your child will be asked to step out of a group photo or have their face covered with a sticker.
  
  Photo Release REQUIRED I approve my child photographs to be published Do not publish my child's photo. Please fill out this field.
  
  By entering into and/or signing this document, the signatory/signatories agree to conduct its/their dealings via electronic means. The signatory agrees that allowing dealings via electronic means will facilitate these dealings. The signatory has the option to opt to sign things in a paper format. If the parent prefers to complete a paper copy of this release, please contact Samuel Cary at the parish.
  
  Parent/Guardian Initials REQUIRED Please fill out this field. Please enter valid data.
  
  Parent/Guardian Electronic Signature (type your name*) REQUIRED Please fill out this field. Please enter valid data.
  
  Submit