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Junior High and High School CYM Registration

- The maximum number of form submissions has been reached. This form is currently not available.
  
  Welcome to CYM! We are so excited to have your student(s) join us for the 2024-2025 school year.
  
  Our Youth Ministry is active all year long with weekly meetings, various special events, retreats and service projects. Throughout the school year we meet on Wednesday evenings from 6:00 - 8:00 pm.
  
  Starting in September, our high school youth (9th-12th grade) meet the 1st, 2nd and 3rd Wednesday of each month. Our junior high youth (7th - 8th grade) meet the 4th Wednesday of each month.
  
  There is no fee for CYM, but we do ask that each family provides a meal during the year for a Wednesday night meeting. A link will be sent to you after you register to sign up for the night you prefer.
  
  If you would rather offer a gift card to help pay for a meal, we suggest at least $50.00. Gift cards to Papa Johns, Little Caesars, Chick fil A, Walmart or Publix are all very helpful.
  
  Thank you so much for sharing your student(s) with us. It's going to be an amazing year centered around our Eucharistic Lord.
  
  Blessed Carlo Acutis.................pray for us!
  
  Family Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Primary Family Cell Number REQUIRED Please fill out this field. Please enter valid data.
  
  Receive Text Message Notifications REQUIRED Yes No Please fill out this field.
  
  Primary Family Email REQUIRED Please fill out this field. Please enter valid data.
  
  Number of Students REQUIRED Please fill out this field.
  
  Student Information 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.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Phone Number Maximum 20 characters Please enter a phone number.
  
  Do we have permission to text your student directly with information and activities pertaining to CYM? Yes No
  
  Student's Email Please enter an email address.
  
  Do we have permission to email your student directly with information and activities pertaining to CYM ? Yes No
  
  Student's Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Student's School REQUIRED Please fill out this field. Please enter valid data.
  
  If your student is of high school age, would they like to be on the teen core team and attend every Wednesday? REQUIRED Yes No I am registering a Jr. High Student Please fill out this field.
  
  Would you prefer to provide a meal or a gift card for a Wednesday Night Meeting? REQUIRED Meal Gift Card Please fill out this field.
  
  Special Concerns CYM should be aware of:
  
  Medical Problems or Conditions (Allergies, Diabetes, etc.) & Symptoms
  
  RELEASE FORMS
  
  Diocese of St. Augustine | Child Photography Release
  
  Without compensation, I hereby grant permission to the Catholic Diocese of St. Augustine to use and reproduce photographs and/or video taken of my child. These photographs may be used for news and editorial purposes in publications and other electronic reproductions (websites and video, including livestream) and/or brochures.
  
  In addition, I grant my permission to alter the same photos without restriction and to copyright the same. I hereby release the photographer, the journalists and the publications or media outlets they represent, as well as, the parish/church and/or school involved, the Bishop of the Diocese of St. Augustine, a corporation sole, the Catholic Diocese of St. Augustine and all of their employees and agents, from all claims and liability relating to said photographs.
  Updated 8/2020
  
  Media Release REQUIRED I Agree I Disagree Please fill out this field.
  
  Diocese of St. Augustine | Medical Matters
  
  I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
  
  (Of the following statements pertaining to medical matters, sign only in accordance with your wishes.)
  
  Emergency Medical Treatement
  In the event of an emergency, I hereby give permission to Diocese of St. Augustine's employees, volunteers, or representatives to seek medical treatment for my child above named.
  
  In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Diocesan representatives or volunteers to hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child above named.
  
  Medical Matters REQUIRED I Agree I Disagree Please fill out this field.
  
  Student Information 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.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Phone Number Maximum 20 characters Please enter a phone number.
  
  Do we have permission to text your student directly with information and activities pertaining to CYM? Yes No
  
  Student's Email Please enter an email address.
  
  Do we have permission to email your student directly with information and activities pertaining to CYM ? Yes No
  
  Student's Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Student's School REQUIRED Please fill out this field. Please enter valid data.
  
  If your student is of high school age, would they like to be on the teen core team and attend every Wednesday? REQUIRED Yes No I am registering a Jr. High Student Please fill out this field.
  
  Would you prefer to provide a meal or a gift card for a Wednesday Night Meeting? REQUIRED Meal Gift Card Please fill out this field.
  
  Special Concerns CYM should be aware of:
  
  Medical Problems or Conditions (Allergies, Diabetes, etc.) & Symptoms
  
  RELEASE FORMS
  
  Diocese of St. Augustine | Child Photography Release
  
  Without compensation, I hereby grant permission to the Catholic Diocese of St. Augustine to use and reproduce photographs and/or video taken of my child. These photographs may be used for news and editorial purposes in publications and other electronic reproductions (websites and video, including livestream) and/or brochures.
  
  In addition, I grant my permission to alter the same photos without restriction and to copyright the same. I hereby release the photographer, the journalists and the publications or media outlets they represent, as well as, the parish/church and/or school involved, the Bishop of the Diocese of St. Augustine, a corporation sole, the Catholic Diocese of St. Augustine and all of their employees and agents, from all claims and liability relating to said photographs.
  Updated 8/2020
  
  Media Release REQUIRED I Agree I Disagree Please fill out this field.
  
  Diocese of St. Augustine | Medical Matters
  
  I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
  
  (Of the following statements pertaining to medical matters, sign only in accordance with your wishes.)
  
  Emergency Medical Treatement
  In the event of an emergency, I hereby give permission to Diocese of St. Augustine's employees, volunteers, or representatives to seek medical treatment for my child above named.
  
  In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Diocesan representatives or volunteers to hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child above named.
  
  Medical Matters REQUIRED I Agree I Disagree Please fill out this field.
  
  Student Information 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.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Phone Number Maximum 20 characters Please enter a phone number.
  
  Do we have permission to text your student directly with information and activities pertaining to CYM? Yes No
  
  Student's Email Please enter an email address.
  
  Do we have permission to email your student directly with information and activities pertaining to CYM ? Yes No
  
  Student's Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Student's School REQUIRED Please fill out this field. Please enter valid data.
  
  If your student is of high school age, would they like to be on the teen core team and attend every Wednesday? REQUIRED Yes No I am registering a Jr. High Student Please fill out this field.
  
  Would you prefer to provide a meal or a gift card for a Wednesday Night Meeting? REQUIRED Meal Gift Card Please fill out this field.
  
  Special Concerns CYM should be aware of:
  
  Medical Problems or Conditions (Allergies, Diabetes, etc.) & Symptoms
  
  RELEASE FORMS
  
  Diocese of St. Augustine | Child Photography Release
  
  Without compensation, I hereby grant permission to the Catholic Diocese of St. Augustine to use and reproduce photographs and/or video taken of my child. These photographs may be used for news and editorial purposes in publications and other electronic reproductions (websites and video, including livestream) and/or brochures.
  
  In addition, I grant my permission to alter the same photos without restriction and to copyright the same. I hereby release the photographer, the journalists and the publications or media outlets they represent, as well as, the parish/church and/or school involved, the Bishop of the Diocese of St. Augustine, a corporation sole, the Catholic Diocese of St. Augustine and all of their employees and agents, from all claims and liability relating to said photographs.
  Updated 8/2020
  
  Media Release REQUIRED I Agree I Disagree Please fill out this field.
  
  Diocese of St. Augustine | Medical Matters
  
  I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
  
  (Of the following statements pertaining to medical matters, sign only in accordance with your wishes.)
  
  Emergency Medical Treatement
  In the event of an emergency, I hereby give permission to Diocese of St. Augustine's employees, volunteers, or representatives to seek medical treatment for my child above named.
  
  In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Diocesan representatives or volunteers to hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child above named.
  
  Medical Matters REQUIRED I Agree I Disagree Please fill out this field.
  
  Student Information 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.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Phone Number Maximum 20 characters Please enter a phone number.
  
  Do we have permission to text your student directly with information and activities pertaining to CYM? Yes No
  
  Student's Email Please enter an email address.
  
  Do we have permission to email your student directly with information and activities pertaining to CYM ? Yes No
  
  Student's Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Student's School REQUIRED Please fill out this field. Please enter valid data.
  
  If your student is of high school age, would they like to be on the teen core team and attend every Wednesday? REQUIRED Yes No I am registering a Jr. High Student Please fill out this field.
  
  Would you prefer to provide a meal or a gift card for a Wednesday Night Meeting? REQUIRED Meal Gift Card Please fill out this field.
  
  Special Concerns CYM should be aware of:
  
  Medical Problems or Conditions (Allergies, Diabetes, etc.) & Symptoms
  
  RELEASE FORMS
  
  Diocese of St. Augustine | Child Photography Release
  
  Without compensation, I hereby grant permission to the Catholic Diocese of St. Augustine to use and reproduce photographs and/or video taken of my child. These photographs may be used for news and editorial purposes in publications and other electronic reproductions (websites and video, including livestream) and/or brochures.
  
  In addition, I grant my permission to alter the same photos without restriction and to copyright the same. I hereby release the photographer, the journalists and the publications or media outlets they represent, as well as, the parish/church and/or school involved, the Bishop of the Diocese of St. Augustine, a corporation sole, the Catholic Diocese of St. Augustine and all of their employees and agents, from all claims and liability relating to said photographs.
  Updated 8/2020
  
  Media Release REQUIRED I Agree I Disagree Please fill out this field.
  
  Diocese of St. Augustine | Medical Matters
  
  I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
  
  (Of the following statements pertaining to medical matters, sign only in accordance with your wishes.)
  
  Emergency Medical Treatement
  In the event of an emergency, I hereby give permission to Diocese of St. Augustine's employees, volunteers, or representatives to seek medical treatment for my child above named.
  
  In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Diocesan representatives or volunteers to hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child above named.
  
  Medical Matters REQUIRED I Agree I Disagree Please fill out this field.
  
  Student Information 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.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Phone Number Maximum 20 characters Please enter a phone number.
  
  Do we have permission to text your student directly with information and activities pertaining to CYM? Yes No
  
  Student's Email Please enter an email address.
  
  Do we have permission to email your student directly with information and activities pertaining to CYM ? Yes No
  
  Student's Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Student's School REQUIRED Please fill out this field. Please enter valid data.
  
  If your student is of high school age, would they like to be on the teen core team and attend every Wednesday? REQUIRED Yes No I am registering a Jr. High Student Please fill out this field.
  
  Would you prefer to provide a meal or a gift card for a Wednesday Night Meeting? REQUIRED Meal Gift Card Please fill out this field.
  
  Special Concerns CYM should be aware of:
  
  Medical Problems or Conditions (Allergies, Diabetes, etc.) & Symptoms
  
  RELEASE FORMS
  
  Diocese of St. Augustine | Child Photography Release
  
  Without compensation, I hereby grant permission to the Catholic Diocese of St. Augustine to use and reproduce photographs and/or video taken of my child. These photographs may be used for news and editorial purposes in publications and other electronic reproductions (websites and video, including livestream) and/or brochures.
  
  In addition, I grant my permission to alter the same photos without restriction and to copyright the same. I hereby release the photographer, the journalists and the publications or media outlets they represent, as well as, the parish/church and/or school involved, the Bishop of the Diocese of St. Augustine, a corporation sole, the Catholic Diocese of St. Augustine and all of their employees and agents, from all claims and liability relating to said photographs.
  Updated 8/2020
  
  Media Release REQUIRED I Agree I Disagree Please fill out this field.
  
  Diocese of St. Augustine | Medical Matters
  
  I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
  
  (Of the following statements pertaining to medical matters, sign only in accordance with your wishes.)
  
  Emergency Medical Treatement
  In the event of an emergency, I hereby give permission to Diocese of St. Augustine's employees, volunteers, or representatives to seek medical treatment for my child above named.
  
  In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Diocesan representatives or volunteers to hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child above named.
  
  Medical Matters REQUIRED I Agree I Disagree Please fill out this field.
  
  Student Information 6
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Phone Number Maximum 20 characters Please enter a phone number.
  
  Do we have permission to text your student directly with information and activities pertaining to CYM? Yes No
  
  Student's Email Please enter an email address.
  
  Do we have permission to email your student directly with information and activities pertaining to CYM ? Yes No
  
  Student's Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Student's School REQUIRED Please fill out this field. Please enter valid data.
  
  If your student is of high school age, would they like to be on the teen core team and attend every Wednesday? REQUIRED Yes No I am registering a Jr. High Student Please fill out this field.
  
  Would you prefer to provide a meal or a gift card for a Wednesday Night Meeting? REQUIRED Meal Gift Card Please fill out this field.
  
  Special Concerns CYM should be aware of:
  
  Medical Problems or Conditions (Allergies, Diabetes, etc.) & Symptoms
  
  RELEASE FORMS
  
  Diocese of St. Augustine | Child Photography Release
  
  Without compensation, I hereby grant permission to the Catholic Diocese of St. Augustine to use and reproduce photographs and/or video taken of my child. These photographs may be used for news and editorial purposes in publications and other electronic reproductions (websites and video, including livestream) and/or brochures.
  
  In addition, I grant my permission to alter the same photos without restriction and to copyright the same. I hereby release the photographer, the journalists and the publications or media outlets they represent, as well as, the parish/church and/or school involved, the Bishop of the Diocese of St. Augustine, a corporation sole, the Catholic Diocese of St. Augustine and all of their employees and agents, from all claims and liability relating to said photographs.
  Updated 8/2020
  
  Media Release REQUIRED I Agree I Disagree Please fill out this field.
  
  Diocese of St. Augustine | Medical Matters
  
  I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
  
  (Of the following statements pertaining to medical matters, sign only in accordance with your wishes.)
  
  Emergency Medical Treatement
  In the event of an emergency, I hereby give permission to Diocese of St. Augustine's employees, volunteers, or representatives to seek medical treatment for my child above named.
  
  In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Diocesan representatives or volunteers to hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child above named.
  
  Medical Matters REQUIRED I Agree I Disagree Please fill out this field.
  
  Student Information 7
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Phone Number Maximum 20 characters Please enter a phone number.
  
  Do we have permission to text your student directly with information and activities pertaining to CYM? Yes No
  
  Student's Email Please enter an email address.
  
  Do we have permission to email your student directly with information and activities pertaining to CYM ? Yes No
  
  Student's Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Student's School REQUIRED Please fill out this field. Please enter valid data.
  
  If your student is of high school age, would they like to be on the teen core team and attend every Wednesday? REQUIRED Yes No I am registering a Jr. High Student Please fill out this field.
  
  Would you prefer to provide a meal or a gift card for a Wednesday Night Meeting? REQUIRED Meal Gift Card Please fill out this field.
  
  Special Concerns CYM should be aware of:
  
  Medical Problems or Conditions (Allergies, Diabetes, etc.) & Symptoms
  
  RELEASE FORMS
  
  Diocese of St. Augustine | Child Photography Release
  
  Without compensation, I hereby grant permission to the Catholic Diocese of St. Augustine to use and reproduce photographs and/or video taken of my child. These photographs may be used for news and editorial purposes in publications and other electronic reproductions (websites and video, including livestream) and/or brochures.
  
  In addition, I grant my permission to alter the same photos without restriction and to copyright the same. I hereby release the photographer, the journalists and the publications or media outlets they represent, as well as, the parish/church and/or school involved, the Bishop of the Diocese of St. Augustine, a corporation sole, the Catholic Diocese of St. Augustine and all of their employees and agents, from all claims and liability relating to said photographs.
  Updated 8/2020
  
  Media Release REQUIRED I Agree I Disagree Please fill out this field.
  
  Diocese of St. Augustine | Medical Matters
  
  I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
  
  (Of the following statements pertaining to medical matters, sign only in accordance with your wishes.)
  
  Emergency Medical Treatement
  In the event of an emergency, I hereby give permission to Diocese of St. Augustine's employees, volunteers, or representatives to seek medical treatment for my child above named.
  
  In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Diocesan representatives or volunteers to hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child above named.
  
  Medical Matters REQUIRED I Agree I Disagree Please fill out this field.
  
  Student Information 8
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Phone Number Maximum 20 characters Please enter a phone number.
  
  Do we have permission to text your student directly with information and activities pertaining to CYM? Yes No
  
  Student's Email Please enter an email address.
  
  Do we have permission to email your student directly with information and activities pertaining to CYM ? Yes No
  
  Student's Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Student's School REQUIRED Please fill out this field. Please enter valid data.
  
  If your student is of high school age, would they like to be on the teen core team and attend every Wednesday? REQUIRED Yes No I am registering a Jr. High Student Please fill out this field.
  
  Would you prefer to provide a meal or a gift card for a Wednesday Night Meeting? REQUIRED Meal Gift Card Please fill out this field.
  
  Special Concerns CYM should be aware of:
  
  Medical Problems or Conditions (Allergies, Diabetes, etc.) & Symptoms
  
  RELEASE FORMS
  
  Diocese of St. Augustine | Child Photography Release
  
  Without compensation, I hereby grant permission to the Catholic Diocese of St. Augustine to use and reproduce photographs and/or video taken of my child. These photographs may be used for news and editorial purposes in publications and other electronic reproductions (websites and video, including livestream) and/or brochures.
  
  In addition, I grant my permission to alter the same photos without restriction and to copyright the same. I hereby release the photographer, the journalists and the publications or media outlets they represent, as well as, the parish/church and/or school involved, the Bishop of the Diocese of St. Augustine, a corporation sole, the Catholic Diocese of St. Augustine and all of their employees and agents, from all claims and liability relating to said photographs.
  Updated 8/2020
  
  Media Release REQUIRED I Agree I Disagree Please fill out this field.
  
  Diocese of St. Augustine | Medical Matters
  
  I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
  
  (Of the following statements pertaining to medical matters, sign only in accordance with your wishes.)
  
  Emergency Medical Treatement
  In the event of an emergency, I hereby give permission to Diocese of St. Augustine's employees, volunteers, or representatives to seek medical treatment for my child above named.
  
  In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Diocesan representatives or volunteers to hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child above named.
  
  Medical Matters REQUIRED I Agree I Disagree Please fill out this field.
  
  Student Information 9
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Phone Number Maximum 20 characters Please enter a phone number.
  
  Do we have permission to text your student directly with information and activities pertaining to CYM? Yes No
  
  Student's Email Please enter an email address.
  
  Do we have permission to email your student directly with information and activities pertaining to CYM ? Yes No
  
  Student's Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Student's School REQUIRED Please fill out this field. Please enter valid data.
  
  If your student is of high school age, would they like to be on the teen core team and attend every Wednesday? REQUIRED Yes No I am registering a Jr. High Student Please fill out this field.
  
  Would you prefer to provide a meal or a gift card for a Wednesday Night Meeting? REQUIRED Meal Gift Card Please fill out this field.
  
  Special Concerns CYM should be aware of:
  
  Medical Problems or Conditions (Allergies, Diabetes, etc.) & Symptoms
  
  RELEASE FORMS
  
  Diocese of St. Augustine | Child Photography Release
  
  Without compensation, I hereby grant permission to the Catholic Diocese of St. Augustine to use and reproduce photographs and/or video taken of my child. These photographs may be used for news and editorial purposes in publications and other electronic reproductions (websites and video, including livestream) and/or brochures.
  
  In addition, I grant my permission to alter the same photos without restriction and to copyright the same. I hereby release the photographer, the journalists and the publications or media outlets they represent, as well as, the parish/church and/or school involved, the Bishop of the Diocese of St. Augustine, a corporation sole, the Catholic Diocese of St. Augustine and all of their employees and agents, from all claims and liability relating to said photographs.
  Updated 8/2020
  
  Media Release REQUIRED I Agree I Disagree Please fill out this field.
  
  Diocese of St. Augustine | Medical Matters
  
  I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
  
  (Of the following statements pertaining to medical matters, sign only in accordance with your wishes.)
  
  Emergency Medical Treatement
  In the event of an emergency, I hereby give permission to Diocese of St. Augustine's employees, volunteers, or representatives to seek medical treatment for my child above named.
  
  In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Diocesan representatives or volunteers to hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child above named.
  
  Medical Matters REQUIRED I Agree I Disagree Please fill out this field.
  
  Student Information 10
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Phone Number Maximum 20 characters Please enter a phone number.
  
  Do we have permission to text your student directly with information and activities pertaining to CYM? Yes No
  
  Student's Email Please enter an email address.
  
  Do we have permission to email your student directly with information and activities pertaining to CYM ? Yes No
  
  Student's Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Student's School REQUIRED Please fill out this field. Please enter valid data.
  
  If your student is of high school age, would they like to be on the teen core team and attend every Wednesday? REQUIRED Yes No I am registering a Jr. High Student Please fill out this field.
  
  Would you prefer to provide a meal or a gift card for a Wednesday Night Meeting? REQUIRED Meal Gift Card Please fill out this field.
  
  Special Concerns CYM should be aware of:
  
  Medical Problems or Conditions (Allergies, Diabetes, etc.) & Symptoms
  
  RELEASE FORMS
  
  Diocese of St. Augustine | Child Photography Release
  
  Without compensation, I hereby grant permission to the Catholic Diocese of St. Augustine to use and reproduce photographs and/or video taken of my child. These photographs may be used for news and editorial purposes in publications and other electronic reproductions (websites and video, including livestream) and/or brochures.
  
  In addition, I grant my permission to alter the same photos without restriction and to copyright the same. I hereby release the photographer, the journalists and the publications or media outlets they represent, as well as, the parish/church and/or school involved, the Bishop of the Diocese of St. Augustine, a corporation sole, the Catholic Diocese of St. Augustine and all of their employees and agents, from all claims and liability relating to said photographs.
  Updated 8/2020
  
  Media Release REQUIRED I Agree I Disagree Please fill out this field.
  
  Diocese of St. Augustine | Medical Matters
  
  I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
  
  (Of the following statements pertaining to medical matters, sign only in accordance with your wishes.)
  
  Emergency Medical Treatement
  In the event of an emergency, I hereby give permission to Diocese of St. Augustine's employees, volunteers, or representatives to seek medical treatment for my child above named.
  
  In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Diocesan representatives or volunteers to hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child above named.
  
  Medical Matters REQUIRED I Agree I Disagree Please fill out this field.
  
  Parent/Guardian Information
  
  Is your family registered at St. Luke's? Yes No
  
  If no, please list church name. Please enter valid data.
  
  Are you interested in volunteering with our youth ministry? REQUIRED Yes No Maybe, I would like more information Please fill out this field.
  
  Areas to Volunteer - Please check where you interested in helping Weekly Meetings - Small groups leaders, meals, topics, etc. Fundraisers - Breakfasts, Bingo, Wreath Across America. etc. Special Events - Dances, Dinners, etc - Parish Wide Service Projects - Wreaths Across America, Parish events, Meals, Community Outreach Days, etc
  
  Have you taken "Protecting God's Children"? (Log on to Virtus.org to register) REQUIRED Yes No Please fill out this field.
  
  Have you had a Diocesan background check? REQUIRED Yes No Please fill out this field.
  
  Parent/Guardian #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.
  
  Relation to Student REQUIRED Please fill out this field.
  
  Parent/Guardian #2
  
  First Name Please enter valid data.
  
  Last Name Please enter valid data.
  
  Relation to Student
  
  Phone Number Maximum 20 characters Please enter a phone number.
  
  Adult Photography Release Form
  Diocese of St. Augustine
  Catholic Center
  11625 Old St. Augustine Rd.
  Jacksonville, Fl 32258
  
  Without compensation, I hereby grant permission to the Catholic Diocese of Saint Augustine to use and reproduce photographs taken of me.
  These photographs may be used for news and editorial purposes in publications, electronic reproductions (websites and video, including livestream) and/or brochures. In addition, I grant my permission to alter the same photos without restriction and to copyright the same.
  
  I hereby release the photographer, the journalists and the publications or media outlets they represent, as well as, the parish/church and/or school involved, the Bishop of the Diocese of St. Augustine, a corporation sole, the Catholic Diocese of Saint Augustine and all of their employees and agents, from all claims and liability relating to said photographs.
  Updated 8/2020
  
  I Agree Please select this field.
  
  Parent/Guardian Signature:
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
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