St. Pius X Youth Ministry Registration

Participant Information

Youth Name

First Name*

Last Name*

Nick Name

Address

Street 1*

Street 2

City*

State*

Zip*

School

Required*

Grade

Required*

Expected Graduation Year

Required*

T-Shirt Size

Required*

Youth E-mail

Required*

Youth Phone

Required* --

Date of Birth

Extracurricular Activities

Sex
Required*

	Female
	Male

Parent/Guardian Information

Mail should be addressed to
Required*

	Parents
	Mother
	Father
	Other (specify)

Other (specify)

FATHER

FATHER'S INFORMATION

Name

First Name

Last Name

Address

Street 1

Street 2

City

State

Zip

E-mail

Phone

MOTHER

MOTHER'S INFORMATION

Name

First Name

Last Name

Address

Street 1

Street 2

City

State

Zip

E-mail

Phone

REGISTERED AT

Required*

If not St. Pius X, please specify at which parish you are registered

EMERGENCY CONTACT INFORMATION

In case of emergency, whom should we contact if we are unable to reach parent/guardian?

Name

First Name*

Last Name*

Relationship

Required*

Phone

Required* --

Name

First Name*

Last Name*

Relationship

Required*

Phone

HEALTH INFORMATION AND SPECIAL NEEDS

	All information will be held in strict confidence.
Physician's Name	Required*
Phone	Required* --
Insurance Company Name	Required*
Medical Insurance ID #	Required*
Cardholder's Name	Required*
Group Number	Required*
Participant's Allergies	If any, including medications and foods**
Participant's Chronic Medical Problems	(e.g. diabetes, epilepsy)**
Participant's Other Physical Restrictions	If any**
Other Notes

SACRAMENTS RECEIVED

Baptism
Required*

	Yes
	No

Date and Location

First Holy Communion
Required*

	Yes
	No

Date and Location

Confirmation

	Yes
	No

Date and Location

Note

If you are in need of any Sacraments, please contact blutz@stpiusxcc.org.

Five Precepts of the Catholic Church

Attend Mass on Sundays	Please make a selection *
Confess your sins at least once a year	Please make a selection
Receive Communion at least during the Easter Season	Please make a selection *
Keep Holy the Holy Days of Obligation	Please make a selection *
Observe the prescribed days of fasting and abstinence	Please make a selection *

PARENT/GUARDIAN DUTIES

Please indicate how you can help.

We need adult volunteers!

	Set-up for Sunday Youth Ministry Nights
	High School CORE Team

	Kitchen Team
	Special Events Volunteer

Spam Capture

PHOTOGRAPHY CONSENT

Photography Consent

As parent/guardian, I understand that photos and video (individual and group) will be taken during youth group events, and I give permission for my son's/daughter's picture to be used for printed or online promotional materials.

Photography Consent
Required*

	I agree
	I disagree

LIABILITY WAIVER

I agree on behalf of myself, my heirs, successors, personal representatives and assign to protect, indemnify, save and hold harmless the Diocese of Corpus Christi and St. Pius X Catholic Church, and their officers, directors, agents employee, or representatives associated with the parish youth program from all damages, claims, suits, expenses and payment on account of our resulting from conditions stated on or resulting from any such injury, death or damage to property, including resulting from the negligence of the Diocese of Corpus Christi, and parish, and or their officers, directors, and employees arising from or in connection with my attending youth ministry/formation events beginning August 1, 2022, and continue through July 32, 2023.

Liability Waiver
Required*

I agree

Date

Required* //

St. Pius X Youth Ministry Registration

Online Giving