SJC Junior High Registration Form
2011-2012

Student Information: Fill out all pertinent information. Please send back to the Office of Youth Ministry, St. Joseph’s Church, Attn.  David Bristow, 750 Peachtree Street, Herndon Va. 20170 or bring it to .  We kindly ask for a one time $25.00 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: ___________________________________
Email: _____________________________________

Date of Birth__________________________
School: ______________________________________________

Interests and Hobbies: ______________________________________________________________
______________________________________________________________

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 complete the following insurance information:

Name of Health Insurer                                    Policy Number

Subscriber’s Name                                            Group Number              Effective Date of Policy

Insurance Company’s Telephone Number

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

Permission to Use Photographs

I hereby authorize the St Joseph Jr. Youth Group to use photographs of my son/daughter provided to or taken by the group, provided such use is non-identifyable and limited to internal reproduction/slide shows and/or the St. Joseph Jr. Youth Group website / blog only.  
_____yes              ____no

Participant Responsibility

I hereby give my permission for the above participant to participate in the regularly scheduled Junior High events once a month at St. Joseph's Church.

________________________________________________            ____________
Parent (and adult witness) Signatures                                              Date