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YM Online Registration 2020-21

- Ministries

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- How many children do you wish to register for Youth Group? REQUIRED Please fill out this field.
  
  Child 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Youth Group REQUIRED Please fill out this field.
  
  Grade Level REQUIRED Please fill out this field.
  
  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.
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  INSURANCE AND MEDICAL INFORMATION
  If you are are unable, we and/or The Archdiocese are authorized to contact the following person(s) for any youth listed in case of sudden illness, accident, or other emergency.
  
  Please list any physical and/or medical needs and medications that staff should be aware of: (Allergies, etc...)
  
  Emergency Contact Name REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Number REQUIRED Please fill out this field. Please enter valid data.
  
  Family Doctor REQUIRED Please fill out this field. Please enter valid data.
  
  Take Youth to Nearest Hospital?
  
  Child 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Youth Group REQUIRED Please fill out this field.
  
  Grade Level REQUIRED Please fill out this field.
  
  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.
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  INSURANCE AND MEDICAL INFORMATION
  If you are are unable, we and/or The Archdiocese are authorized to contact the following person(s) for any youth listed in case of sudden illness, accident, or other emergency.
  
  Please list any physical and/or medical needs and medications that staff should be aware of: (Allergies, etc...)
  
  Emergency Contact Name REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Number REQUIRED Please fill out this field. Please enter valid data.
  
  Family Doctor REQUIRED Please fill out this field. Please enter valid data.
  
  Take Youth to Nearest Hospital?
  
  Child 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Youth Group REQUIRED Please fill out this field.
  
  Grade Level REQUIRED Please fill out this field.
  
  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.
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  INSURANCE AND MEDICAL INFORMATION
  If you are are unable, we and/or The Archdiocese are authorized to contact the following person(s) for any youth listed in case of sudden illness, accident, or other emergency.
  
  Please list any physical and/or medical needs and medications that staff should be aware of: (Allergies, etc...)
  
  Emergency Contact Name REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Number REQUIRED Please fill out this field. Please enter valid data.
  
  Family Doctor REQUIRED Please fill out this field. Please enter valid data.
  
  Take Youth to Nearest Hospital?
  
  Child 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Youth Group REQUIRED Please fill out this field.
  
  Grade Level REQUIRED Please fill out this field.
  
  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.
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  INSURANCE AND MEDICAL INFORMATION
  If you are are unable, we and/or The Archdiocese are authorized to contact the following person(s) for any youth listed in case of sudden illness, accident, or other emergency.
  
  Please list any physical and/or medical needs and medications that staff should be aware of: (Allergies, etc...)
  
  Emergency Contact Name REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Number REQUIRED Please fill out this field. Please enter valid data.
  
  Family Doctor REQUIRED Please fill out this field. Please enter valid data.
  
  Take Youth to Nearest Hospital?
  
  Child 5
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Youth Group REQUIRED Please fill out this field.
  
  Grade Level REQUIRED Please fill out this field.
  
  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.
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  INSURANCE AND MEDICAL INFORMATION
  If you are are unable, we and/or The Archdiocese are authorized to contact the following person(s) for any youth listed in case of sudden illness, accident, or other emergency.
  
  Please list any physical and/or medical needs and medications that staff should be aware of: (Allergies, etc...)
  
  Emergency Contact Name REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Number REQUIRED Please fill out this field. Please enter valid data.
  
  Family Doctor REQUIRED Please fill out this field. Please enter valid data.
  
  Take Youth to Nearest Hospital?
- ___________________________________________
  
  Registration Fees
  ___________________________________________
- Number of Children Registered Above for Youth Group REQUIRED Please fill out this field.
- This amount per child does not combine with students in grades pre-K – 5
Total:

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