Youth Ministry Registration Form (Grades 8 - 12)

*Our youth are welcome to attend events at any of our sites. You need to register only once.

Youth's Name: (required)

Youth's Date of Birth (*): (required)

Address: (required)

Home Phone: (required)

Grade Number (as of September 2017): (required)

Please select the site you will most likely attend: (required)

Father's Name:

Father's Cell Number:

Father's Email:

Mother's Name:

Mother's Cell Number:

Mother's Email:

Who does the youth live with: (required)

In case of emergency( if parent cannot be reached), please contact: (required)

Emergency contact phone number: (required)

Emergency - relationship to youth: (required)

Does your youth have any allergies or any other important medical information that we need to know about? (required)

If there are any allergies or medical issues, please list them:

Is your youth covered under insurance? (required)

Insurance company:

Policy holder:

Policy number:

Physician's name:

Physician's phone number:

Do we have permission for Blessed Trinity / St. Patrick Parish to make use of the pictures of your youth for informational / advertising purposes only for church web site, bulletin boards, and media releases? (required)

Preferred Email (required):

Additional comments:

By hitting the 'submit' button below: I hereby certify that the above information is correct and give permission for my youth to be transported in privately owned vehicles for medical emergencies only, and for the release of medical records to an attending health care professional in case of illness. I understand that every effort will be made to contact the parent or guardian. If one cannot be contacted, I hereby give permission for a qualified physician to secure proper treatment for my youth.My youth will also comply with the rules for all Parish Youth Group meetings/retreats and Diocese of Rochester Youth Ministry events as mentioned in the Youth Code of Conduct section.

Youth Code of Conduct

  • The purchase, possession or consumption of alcoholic beverages or the possession or use of illegal drugs will not be tolerated. Failure to comply will result in IMMEDIATE DISMISSAL from the youth group meeting/event.
  • Cigarette smoking and chewing of tobacco will not be allowed at any time.
  • Youth must attend all scheduled activities and events and remain in areas of the campus designated for a Parish or Diocese of Rochester event.
  • Participants must remain on campus until their transportation departs at the end of the event.
  • Youth are expected to obey the direction of the Youth Minister and chaperones at all times.
  • Youth are expected to use appropriate behavior and language. No dangerous play will be allowed at any meeting/event.
  • Final decisions regarding acceptable behavior/consequences is the responsibility of the Youth Minister at a youth group meeting or Parish event.
  • You are welcome and encouraged to bring a friend to Parish events as long as they are of the appropriate age (7-12 grade) and have filled out a visitor’s form and have signed the Code of Conduct.

We have read the information/expectations on this form and agree to abide by the Code of Conduct. If these rules are violated, we accept responsibility for the behavior and will arrange, at our own expense when deemed necessary, for the transportation of the child if he/she is dismissed from the youth group meeting/event.





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Microsoft Internet Explorer: (YYYY-MM-DD)
2016-01-05

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Google Chrome: (has the ability to click and select a date, but uses MM-DD-YYYY)

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