Year One Confirmation

Candidate's Information

Candidate's Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Cell Number*

Area CodePhone Number

E-mail*

Date of Birth*

MM/DD/YYYY

Name of High School*

Graduating Class Year*

Date of Baptism*

MM/DD/YYYY

Church of Baptism*

Church of First Communion*

The complete sacrament record is compiled at the parish of Baptism. Please provide accurate information so that a Certificate of Confirmation can be forwarded promptly. If the church of baptism is not St. Pius X, a copy of the candidate's baptismal certificate must be provided as part of this application. You can email a copy to confirmation@stpiusxloudonville.org or stop by the office to have a copy made for you.

As a participant of the St. Pius X Youth Ministry/ Confirmation Programs, I understand and agree to the rules and regulations as determined St. Pius X Church and the Roman Catholic Diocese of Albany . I also understand and agree that I will notify my parents or guardian at the time of any infractions requiring my dismissal from the event and that I will be sent home at my own and/or my parent’s or guardian’s expense.

Consent*

I agree

Parent Information

Parent One's Name*

First NameLast Name

Parent One's Preferred Phone*

Area CodePhone Number

Parent One's Preferred E-mail*

example@example.com

Parent Two's Name

First NameLast Name

Parent Two's Preferred Phone

Area CodePhone Number

Parent Two's Preferred E-mail

example@example.com

I/we, the parent(s) named above, grant permission for my child to participate in St. Pius X Youth Ministry/ Confirmation opportunity. I am aware that cell phone coverage is not always available and sometimes not available at all. I am fully aware that my child may require transportation by a core team member. I understand that said transportation will be determined on an as needed basis with what ever means available to the supervising core team member. This member and all drivers will not be less than 21 years old.
I grant permission, if needed, for my child to be evaluated, diagnosed, treated, and /or medicated in accordance with standard medical practice by licensed medical personnel. I relieve St. Pius X Church and the Roman Catholic Diocese of Albany of all responsibility and consequences that may arise as the result of this treatment.
I will not hold St. Pius X Church, the Roman Catholic Diocese of Albany, or any and all other participating chaperones responsible in the event of injury. Further, I agree to accept any and all financial responsibility as a result of scheduling such treatment.
My child agrees to abide by all rules and regulations decided upon by the St. Pius X Church and the Roman Catholic Diocese of Albany. I understand that neither St. Pius X nor the Roman Catholic Diocese of Albany will be held liable if my child fails to cooperate with said regulations and that any infractions of the rules may result in immediate dismissal from the event. I further understand that I will be responsible for any costs or other requirements for immediate transportation home. The participant will not be left unattended while waiting for transportation home.
Media/Photo Waiver: I hereby authorize and give my full consent to St. Pius X Youth Ministry/ Confirmation Chaperones to copyright and/or publish any and all photographs, videotapes and/or film in which my child or myself appear while participating in any programs sponsored or chaperoned by St. Pius X Youth Ministry/ Confirmation Programs. I further agree that they may transfer, use or cause to be used, these photographs, videotapes, or films for any exhibitions, public displays, publications, commercials, art and advertising purposes and television programs without limitations or reservations.

Consent*

I agree

Candidate's Medical Information

Insurance Provider

Policy Number

Primary Policy Holder

Allergies:

Diet Restrictions:

Any physical limitations or special medical conditions?

IN CASE OF EMERGENCY and I cannot be reached, please notify:

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Relation to Candidate*

Permission for Photographs/Video

As the parent(s) listed above, I hereby authorize and give my consent for the taking of pictures (moving or still) of the above named teen and further give permission for their reproduction for: teaching purposes, news releases, social media, publications and/or community awareness.

Photo/Video Permission*

yesno

Are you/your family registered as parishioners with St. Pius X?

yesno

Once you hit "submit form" you will be directed to our payment page automatically.