High School Youth Group Registration

Student Last Name REQUIRED Please fill out this field. Please enter valid data.

Student First Name REQUIRED Please fill out this field. Please enter valid data.

Birthdate REQUIRED Please fill out this field. Please enter a date.

Gender REQUIRED Male Female Please fill out this field.

School Name 2020-2021 REQUIRED Please fill out this field. Please enter valid data.

Grade Level 2020-2021 REQUIRED Please fill out this field. Please enter valid data.

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.

Mother's Name REQUIRED Please fill out this field. Please enter valid data.

Mother's Cell REQUIRED Please fill out this field. Please enter a phone number.

Father's Name REQUIRED Please fill out this field. Please enter valid data.

Father's Cell REQUIRED Please fill out this field. Please enter a phone number.

Parents' Primary Email REQUIRED Please fill out this field. Please enter an email address.

Youth Contact Information (From time to time we will send messages/emails as reminders and/or to communicate with members of the youth group. There will always be at least 2 adults involved in the messaging/emails)

Youth's Email REQUIRED Please fill out this field. Please enter an email address.

Youth's Cell Phone REQUIRED Please fill out this field. Please enter a phone number.

I (youth) would like to be included on all youth communication (email and messages) REQUIRED Yes, please include me on all messages and emails No Please fill out this field.

Does your child have a medical condition, food allergies, or behavioral issues? Please indicate below any special circumstances regarding your child or family. If allergy is potentially life threatening, please meet with the Director to discuss. REQUIRED Yes No Please fill out this field.

If yes, please explain.

Emergency Contact - Name | Phone | Relationship REQUIRED Please fill out this field. Please enter valid data.

Physician - Name | Phone REQUIRED Please fill out this field. Please enter valid data.

In the event that a parent/guardian cannot be reached, I hereby give my consent to Christ the King Catholic Church to contact the physician listed above, and, if necessary, transport my child to a clinic or hospita REQUIRED I agree I do not agree Please fill out this field.

I hereby give Christ the King Catholic Church permission to publish pictures of my child on the parish website, social media, and/or parish publications. (Please note: No names will be included with pictures). REQUIRED I agree I do not agree Please fill out this field.

I am interested in helping as a volunteer for Youth Group REQUIRED Yes No Maybe, but I would like more information first Please fill out this field.

I give my child permission to participate in Youth Group online meetings. *Following Safe Environment guidelines as set forth by the Archdiocese of Omaha REQUIRED I agree I do not agree Please fill out this field.

High School Youth Group Registration

Youth Group Registration
Grades 9-12

Youth Group Registration (Grades 7-8)