High School/ LifeTeen Registration/Church of the Holy Family Catholic Church/Virginia Beach, VA

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

Grade REQUIRED

If you are registering your son/daughter for confirmation please complete the confirmation form as well.

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 Please fill out this field. Please enter valid data.

State REQUIRED 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?

If No, child resides with Please enter valid data.

Medical Information

Is the participant allergic to anything? REQUIRED 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 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 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.