SJC High School Registration Form 11-12

Student Information: Fill out all pertinent information. Please send back to Church Office attention Mr. Bristow. We kindly ask for a $30.00 donation (if your means allow) payable to St. Joseph’s Church. It is used to cover costs associated with the program.

Name ____________________________________________________________________________________

Address: _____________________________________________________ City/Zip:_____________________

Home Phone: ___________________________________

Date of Birth __________________________ School : ______________________________________________

Interests & Likes: _________________________________________________________________

__________________________________________________________________________________

Parent Information:

Parent(s)/Guardian Name: ____________________________________________________________________

Parent Phone Home: ___________________________ Work Phone: __________________________________

Parent Email: (Please provide if you wish to be on our email list) _____________________________________

Emergency Contact: ___________________________ Emerg. Phone: ________________________________

Health Information:

In order to provide the safest and most prepared environment possible, please make available a copy of your son/daughter’s insurance card in the boxes below (front and back). This allows the youth office to have insurance information readily available in case of an unforeseen emergency*. If you have any questions, please contact the youth office at 703-880-4309.

Is it okay to take pictures of your youth at schedule youth events for posting on the Church /youth group website or blog in a non-idenitfying fashion? _________

Does your teenager take any prescribed medications or is he or she allergic to anything? ___________________________

*Please note: We kindly ask that parents fill out a registration form each year so as to account for insurance changes. If insurance provider changes and/or is altered in the year, it is the responsibility of the parent/guardian to inform the youth office of these changes. If you do not have an insurance card with your plan, please provide the insurance carrier, the group and/or ID number, telephone number of the provider, and any other relevant information.

Parental Assistance Form:

As parents of your teenager(s), we greatly need your support and assistance as we develop this innovative ministry program for the upcoming school year. Please fill out the below form if you want to find out more information on how you can be of assistance.  

Parent/Guardian Name: _____________________________________________________________________

Address:__________________________________________________________________________________

Phone: ____________________________________

Email:_____________________________________

Please check off those areas which you might be able to assist in. We truly appreciate your support.

____ Hospitality Meal (i.e. preparing a meal for a Sunday Night Youth gathering - two (2) parents for each night)

____ Chaperone (i.e. providing transportation to and from off-site events)

____ Service Lead (i.e. being a lead parent for one of the many service events throughout the year)

____ Sunday Night Assistant (i.e. being an able "behind the scenes" adult at certain deisgnated youth nights)

Please return all applicable forms and payments to the Office of Youth Ministry, St. Joseph’s Church, 750 Peachtree Street, Herndon Va. 20170.