YOUTH MINISTRY Registration Form

SJN YOUTH MINISTRY Registration Form
Mailing Address: 8900 Lochaven Drive, Gaithersburg, MD 20882

Street Address: 9000 Warfield Road, Gaithersburg, MD 20882

Office Phone: 301-977-7990

Fax: 301-330-3235

Email: mstoolmiller@saintjohnneumann.org
Family Information
TEEN'S PLACE OF RESIDENCE *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Family E-mail
Parents' Information
Father's Name

First Name Middle Name Last Name
Home Phone Number

Area Code Phone Number
Mobile Number

Area Code Phone Number
Work Number

Area Code Phone Number
E-mail
Mother's Name

First Name Middle Name Last Name
Home Phone Number

Area Code Phone Number
Mobile Number

Area Code Phone Number
Work Number

Area Code Phone Number
E-mail

Emergency Medical Information
Name of Insurance Company
Policy Number
Name of TEEN'S Physician

First Name Last Name
Phone Number

Area Code Phone Number

Hey Parents! Would you like to help out as a Volunteer?

If so, please make sure that we have your contact information at the beginning of this form.
Would you like to volunteer? *

Yes, I would like to volunteer. No, I would not like to volunteer at this time
Almost Finished!

We need your consent to continue.

Parent (or Legal Guardian) Consent:

Please read carefully:
1. I authorize the staff of St. John Neumann Catholic Church (salaried and/or volunteer) to administer First Aid and/or take my teen(s) to a physician or hospital for emergency treatment in the event it appears necessary and neither parent nor guardian can be contacted. We will notify the Rescue Squad in emergency situations.
2. Parents/guardians of participants are advised that photographs or video of participants may be used in publications, websites or other materials produced from time to time by St. John Neumann Catholic Church/Archdiocese of Washington. (Participants would not be identified, however, without specific written consent.) Parents/guardians who do not wish their child to be photographed or filmed must notify the parish in writing. Please note that the parish has no control over the use of photographs or film taken by media that may be covering the event in which your child participates.
3. As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“participant”). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St. John Neumann Parish, its officers, directors and agents, and the Archdiocese of Washington, chaperones, or representatives associated with the St. John Neumann Youth Group, arising from or in connection with my child attending St. John Neumann Youth Group activities or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors and agents, and the Archdiocese of Washington, chaperones, or representatives associated with the St. John Neumann Youth Group for reasonable attorney’s fees and expenses arising in connection therewith.
Parent (or Legal Guardian) Consent required to complete registration *

I consent
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SJN YOUTH MINISTRY Registration Form

Family Information

Parents' Information

TEEN'S Information

Emergency Medical Information

Hey Parents! Would you like to help out as a Volunteer?