St. John Vianney Family Life Center Youth Registration Form

You will NOT be allowed to participate unless this form is PROPERLY

Completed and signed by a parent or a guardian.

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PARTICIPANT INFORMATION/MEDICAL EMERGENCY FORM

Participant’s Name ______ Nick Name ___________________ ____

Name of Parent/Guardian/Custodian

Address

City____________________________________________ State________________ Zip Code_____________________

Home Phone Father’s work # ____ Mother’s work # ________

E-Mail Address ____Cell Phone # ________________

Home Parish__________________________________________ Date of Birth ________________________________

Catholic ( ) Non-Catholic ( ) Male ( ) Female ( ) Grade _____ CCD student @ SJV____________

Emergency Contact Person Phone

If this child has any on-going medical problems, please indicate:

If the child is currently taking any form of medication, please indicate type of

medication/frequency:

I hereby authorize the coach, director, building monitor or volunteer present at St. John Vianney Family Life Center to seek immediate medical treatment for my child listed above, if a medical emergency arises while on the way to, returning from, or during any practice, game or meet in which the team participates. I also authorize the attending physician to perform any emergency treatment necessary after the consultation with the coach if I cannot be reached.

Parent/Guardian/Custodian Signature Date

Assumption of Risk

The parent, guardian or custodian by executing this registration for and on behalf of the named participant represents and warrants that they are unaware of any physical or mental impediment that would or could cause injury or harm to the participant or to others by the said participant’s participation in the activities of the St. John Vianney Family Life Center. Due to the strenuous nature of some activities, the parent, guardian, or custodian is urged to consult a physician concerning the fitness of the participant to engage in activities prior to executing this registration. Since all activities present certain inherent and/or inadvertent risks and hazards, know and acknowledge by the undersigned, the parent, guardian or custodian, by their execution hereof, approve the participant’s participation and assume all liability incident to the said minor’s participation, except that liability, which is imposed by law on the Catholic Archdiocese of Washington, their employees, agents or volunteers.

Parent/Guardian/Custodian Signature: Date: