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Home
Parish Mission 2020
Mass LIVE Stream
Moving Forward in Faith
Online Giving
CRS Rice Bowls
LENT 2021
Human Trafficking Teen Talk
Our Parish
Our Church
Living Our Mission
Staff
Holy Family Statue
Contact Us
Parish Registration
Holy Family Day School Payment
Parish Gift Shop
Diocese of Richmond History
Communications
Bulletin
Resources
Virtus and Safe Environment
Our Faith
Catholicism
Why Catholic?
The Real Presence of Christ
Coming Back to the Catholic Faith
Liturgy
Mass & Confession Times
Funeral Information
Funeral Information
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The Sacraments
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Service
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Forms
Online Ministry Form
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EDGE / LifeTeen Registration
The maximum number of form submissions has been reached. This form is currently not available.
Please complete one form per child.
Youth Information
First Name
REQUIRED
Please fill out this field.
Please enter valid data.
Last Name
REQUIRED
Please fill out this field.
Please enter valid data.
Cell Phone Number
REQUIRED
Please fill out this field.
Please enter a phone number.
Date of Birth
REQUIRED
Please fill out this field.
Please enter a date.
Gender
None
Male
Female
Grade
REQUIRED
If you are registering your son/daughter for confirmation please complete the confirmation form as well.
(Select One)
6th
7th
8th
9th
10th
11th
12th
Please fill out this field.
School
Please enter valid data.
Sacraments Received
REQUIRED
Baptism
First Penance
First Communion
Need Baptism
Please fill out this field.
Participating:
REQUIRED
In-person
Virtual
Please fill out this field.
My teen has special needs: yes/no If yes, how can we be of assistance?
Parent/Guardian Information
Father
First Name
Please enter valid data.
Last Name
Please enter valid data.
Religion
Please enter valid data.
Phone Number
REQUIRED
Please fill out this field.
Please enter a phone number.
Mother
First Name
Please enter valid data.
Last Name
Please enter valid data.
Religion
Please enter valid data.
Phone Number
REQUIRED
Please fill out this field.
Please enter a phone number.
Address
REQUIRED
Please fill out this field.
Please enter valid data.
City
REQUIRED
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Please enter valid data.
State
REQUIRED
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
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OK
OR
PA
PR
PW
RI
SC
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TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Please fill out this field.
Zip
REQUIRED
Please fill out this field.
Please enter a zip code.
Email
REQUIRED
Please fill out this field.
Please enter an email address.
Do both parents’ reside in the home?
None
Yes
No
If No, child resides with
Please enter valid data.
Medical Information
Is the participant allergic to anything?
REQUIRED
(Select One)
Yes
No
Please fill out this field.
List any details of allergies below (this may include food allergies, allergies to specific medications or chemicals, allergies to any substances):
REQUIRED
Please fill out this field.
Is the participant currently taking or has taken any prescription medication in the last 6 months?
REQUIRED
(Select One)
Yes
No
Please fill out this field.
List the specific prescription medications, reasons for medication, and daily dosage. Indicate if the medication is currently being administered.
REQUIRED
Please fill out this field.
Does the participant have any emotional, physical or sensory conditions?
REQUIRED
(Select One)
Yes
No
Please fill out this field.
List any emotional conditions that may impede participation in the event. This may include counseling, treatment for emotional conditions (i.e. depression, eating disorders), and/or family situations that may have a significant impact on the participant.
List any physical and/or sensory conditions of which we should be aware or of which need special accommodations (e.g. hearing loss, visual impairment, mobility).
Release of Liability and Medical Release
As parent and/or legal guardian I remain legally responsible for any personal actions taken by the above named minor. I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend
Church of the Holy Family
the Catholic Diocese of Richmond, its employees and agents, chaperones, or representatives associated with this event from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the Diocese, its employees and agents and chaperones, or representatives associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the Diocese.
I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. In the event of any emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers I give permission for the noted emergency contact to be notified. I will not hold
Church of the Holy Family
and the Diocese of Richmond responsible for authorizing any medical treatment beyond necessary transportation to the hospital.
I Agree
Please select this field.
Use of Picutres and/or Video
I give permission for pictures and/or video of my child (named above) engaged in activities related to Church of the Holy Family or Diocesan event to have their pictures posted in
Church of the Holy Family
the Diocese of Richmond publications or websites. Names of participants
will not
be used without express permission from the parent or guardian. If no box is checked below, Church of the Holy Family the Diocese of Richmond assumes you give permission.
USE OF PICTURES AND/OR VIDEO
REQUIRED
Yes
No
Please fill out this field.
Christian Formation Registration Fee
REQUIRED
50
– High School Fee
Please fill out this field.
Total:
Submit
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