Senior High Registration

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Senior High Registration

Questions? Call Parker Andries, Coordinator of Jr. High Youth Ministry at (318) 487-8593 ext. 229 or email [email protected] for more information.

Teen Information

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Teen Cell Phone *

Teen Email *

Age *

Date of Birth *

Grade *

School *

List any jobs, teams, groups, or extracurricular activities that you are involved with during the school year. *

Parent/Guardian Information

Parent/Guardian Name *

First

Last

Parent/Guardian Phone *

Parent/Guardian Email *

Emergency Information

Emergency Contact Name *

First

Last

Must be someone other than parent/guardian that is already listed.

Emergency Contact Phone *

Teen's Doctor's Name *

First

Last

Doctor's Phone Number *

Allergies *

Please list all allergies.

Medications *

Please list all medication that your child takes regularly.

Parental Authorization

If necessary, may I give your child Tylenol? *

May I post photos of your child on our social media pages? *

Parent Permission

I give permission for my child to take part in the Our Lady of Prompt Succor Youth Program activities on and off church grounds. In consideration of the opportunity for my child to participate and fully recognizing that such an undertaking involves an element of risk, we assume all risks and hazards incidental to such participation and do herby release, absolve indemnify, and agree to hold harmless the Diocese of Alexandria and Our Lady of Prompt Succor Church, its agents, employees and officers, the chaperones, leaders, organizers, sponsors, and persons transporting our child to and from these activities. Neither the Diocese of Alexandria and Our Lady of Prompt Succor Church, nor any of said persons shall be held financially responsible for any injury, illness, or death incurred as a direct or indirect result of this activity. I, the undersigned, have read this release and understand all its terms and execute it voluntarily and with full knowledge of its significance. In the event of an emergency and I cannot be contacted, I hereby authorize that emergency treatment may be administered.

Parent Electronic Signature *

Please type your name to sign.

Today's Date *

Registration Fee *

Price: $30.00

Senior High Registration