Steubenville Toronto Youth Conference

Initial Registration Form (Parish Portion)

August 7-9, 2015
Youth Ministry Coordinator: Lisa (905) 812-0030 ext. 7 ym@mercifulredeemer.org
http://mercifulredeemeryouth.com

1. PARTICIPANT INFORMATION
Full Name:

School:

(print clearly)

Gender:
F (circle)

Email:

Denomination:

Cell Phone:

T-Shirt Size (circle one): S

XL
XXL (all adult sizes)

Age:
M

Grade:

2. PARENTAL & EMERGENCY CONTACT INFORMATION

Parent/Guardian Name

Parent/Guardian Name

(First & Last):

(First & Last):

Home:

Cell:

Work:

Email:

Home:

Cell:

Work:

Email:

3. MEDICAL INFORMATION & TREATMENT

If needed, I give permission for me/my youth to be evaluated, diagnosed, treated and/or given medication in
accordance with standard medical practice by licensed medical personnel. I understand that attempts to contact me
(for youth), if necessary, will be made. I relieve Merciful Redeemer Parish, all volunteers, chaperones & staff of all
responsibility and consequences that may arise as a result of this treatment, and I will not hold any of the above
mentioned parties liable in the event of injury or illness. I agree to accept any and all financial responsibility as a result
of scheduling medical treatment.
Medical Information

(print clearly)::

Allergies
Medications:

Health Card No.:

Physician Name:

Physicians Phone:

5. PHOTOS & VIDEOS

I am aware that photos and videos may be taken during events and permit the use or publishing of these photos
and/or videos of me or my child on Merciful Redeemer Parish promotional material, including Facebook, the Merciful
Redeemer Youth Ministry Weblog and other Internet sites.
6. RULES, REGULATIONS & LIABILITY
I/my youth agree to abide by the rules & regulations stated by Merciful Redeemer Parish, all volunteers, chaperones
and staff, including the stipulation that alcohol, drugs and weapons are not permitted. I understand that if I/my youth
fail(s) to comply with these rules & regulations, it may result in immediate dismissal from the event with transportation
costs at my expense. I also agree to release Merciful Redeemer Parish, all volunteers, chaperones and staff of any
liability in the case of any accident that may occur as a result of my/my youths participation in this event.
7. PARENTAL PERMISSION TO GET A RIDE WITH SOMEONE OTHER THAN PARENT/GUARDIAN
__________
NO __________
(such as a friend or friends parent) **PARENT INITIALS ** (Checkmarks are not accepted)

YES

8. COMMITMENT STATEMENT AND SIGNATURES

I, ______________________________, parent/legal guardian of ___________________________ , do hereby attest that both
myself and my child have read all of the information concerning registration for and participation in the Steubenville
Toronto Youth Conference on August 7-9, 2015 in Toronto, ON with Merciful Redeemer Parish. I understand that in order
for my child to attend this conference, we must be committed to paying all fees on time, and attending a mandatory
meeting in Summer 2015.

I also understand that the deposit and any additional paid fees are non-refundable, but that they are transferable,
meaning that in the event of not being able to attend the conference, my child can find someone else to take up
his/her spot, provided that other person pays all the applicable fees.
Participant:
Signed

Print Name

Date

Signed

Print Name

Date

Signed

Print Name

Date

Parent(s)/Guardian(s):