High School YG Form

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  2025-2026 High School Youth Group Release Form
  
  Number of Children Please fill out this field.
  
  Child Info 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.
  
  Food Sensitivities/Allergies/Medications/Other REQUIRED Please fill out this field. Please enter valid data.
  
  School REQUIRED Please fill out this field. Please enter valid data.
  
  Current Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Child Info 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.
  
  Food Sensitivities/Allergies/Medications/Other REQUIRED Please fill out this field. Please enter valid data.
  
  School REQUIRED Please fill out this field. Please enter valid data.
  
  Current Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Child Info 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.
  
  Food Sensitivities/Allergies/Medications/Other REQUIRED Please fill out this field. Please enter valid data.
  
  School REQUIRED Please fill out this field. Please enter valid data.
  
  Current Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Child Info 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.
  
  Food Sensitivities/Allergies/Medications/Other REQUIRED Please fill out this field. Please enter valid data.
  
  School REQUIRED Please fill out this field. Please enter valid data.
  
  Current Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Family Information
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Street Address REQUIRED Please fill out this field. Please enter valid data.
  
  City Please enter valid data.
  
  State
  
  Zip Please enter a zip code.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  MEDICAL RELEASE
  As a parent/guardian, I do hereby authorize the treatment by a qualified and licensed physician of any condition which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me.
  I further authorize the person who presents the minor to sign the Acknowledgement of Receipt of Notice Privacy Rights that may be presented by the physician or health care facility. This authorization is complete and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician.
  I Agree Please select this field.
  
  Family Physician Data
  
  Physician/Office REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Health Insurance Data
  
  Company REQUIRED Please fill out this field. Please enter valid data.
  
  Group # REQUIRED Please fill out this field. Please enter valid data.
  
  Policy # REQUIRED Please fill out this field. Please enter valid data.
  
  Contract REQUIRED Please fill out this field. Please enter valid data.
  
  PHOTO RELEASE
  I hereby grant permission to St. Monica Parish to publish my child's photo, or video image in connection with a display, feature story or other publication as deemed appropriate by the parish. This photo may be used in connection with: parish bulletin boards, publicity materials, school website or parish website and parish's social media.
  I Agree Please select this field.
  
  By entering into and/or signing this document, the signatory/signatories agree to conduct its/their dealings via electronic means. The signatory agrees that allowing dealings via electronic means will facilitate these dealings. The signatory has the option to opt to sign things in a paper format. If parent prefers to complete a paper copy of this release, please contact the Youth Minister at the parish.
  
  Parental/Guardian Initials REQUIRED Please fill out this field. Please enter valid data.
  
  Please list anyone NOT allowed to transport your child home from events. Please enter valid data.
  
  Parental/Guardian Electronic Signature REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  Submit
  
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High School YG Form

2025-2026 High School Youth Group Release Form

Family Information