Middle and High School Only

Registration and Liability form for youth attending an event in Hampton Roads 2019-2020
(This form is kept on file and is used for all youth events.)
(All fields are required)

Youth Information
Youth Name:
First Name:
Youth Address:
Youth Phone:
Youth Email:
Dietary Requirements:
Youth Gender:
Youth Age:
Youth Birthdate:
Youth School:
Youth Grade:
Adult Shirt size:

Parent Information
If either parent is not available, place the same information in both sections.
Mother's Name:
Mother's Cell #:
Mother's Email:
Father's Name:
Father's Cell #:
Father's Email:
Emergency Contact
This should be a non-parental contact.
Contact #:
Relationship to child:

Medical Information
In many cases, our staff and volunteers are not familiar with the medical, physical, and/or emotional history of each participant. Please share ANY information relating to the participant in detail. BE AS SPECIFIC AS POSSIBLE. Add additional sheets if needed.
Any text area item in this section can be left blank if the preceding question is "No".
Does the participant have any dietary restrictions?
Select any restrictions that apply to this participant (optional)
Other Dietary Restrictions
Is the participant allergic to anything?
List of allergies
Is the participant currently taking or has taken any prescription medications in the last 6 months?
List of medications
Does the participant have any emotional, physical or sensory conditions?
List of conditions

Event Preferences
The following information will be used if your child is selected to attend the Diocesan Youth Conference.
I am interested in participating in the Youth Choir for Mass at the Youth Conference:
Sung part or instrument:
Prince of Peace is participating in the optional Sunday Lunch, please select the preferred sandwich:
HamTurkeyChicken SaladVeggie Wrap

Use of Media Images
I give permission to for pictures and/or videos of my child (named above) engaged in activities related to any Diocesan or Prince of Peace event to have their pictures posted in publications or websites. Names of participants will not be used without expressed permission from the parent or guardian. If the "no" box is not checked below, the Diocese of Richmond and Prince of Peace Catholic Church assumes you give permission.
Permission Granted:
Parent/Guardian Signature:
Today's Date:

Release of Liability and Medical Release
There are TWO check boxes that must both be checked before you can submit this form.

Parent/Guardian Signature:
Today's Date: