'26-'27 Middle School Youth Group Registration

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  2026-2027 Student Information
  
  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.
  
  Age 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.
  
  Address if different from Primary Parent 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.
  
  Age 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.
  
  Address if different from Primary Parent 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.
  
  Age 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.
  
  Address if different from Primary Parent 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.
  
  Age 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.
  
  Address if different from Primary Parent 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.
  
  Relationship to Minor: 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 - Primary Parent REQUIRED
  
  Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Second Parent/Guardian Information (optional)
  
  First Name Please enter valid data.
  
  Last Name Please enter valid data.
  
  Relationship to Minor: Please enter valid data.
  
  Street Address Please enter valid data.
  
  City Please enter valid data.
  
  State
  
  Zip Please enter a zip code.
  
  Phone Number
  
  Please enter a phone number.
  
  Include to receive emails at this address too. Please enter an email address.
  
  Medical Treatment Authorization
  
  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 Acknowledgment of Receipt of Notice Privacy Rights that may be presented by the physician or health care facility. 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. I fully understand and agree to the above terms and sign this form knowingly, willingly and freely. This authorization is completed 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
  
  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
  
  We respect your right to privacy, if you do not want your child's name or photographs used please check below.
  Please realize that your child will be asked to step out of a group photo, or have their face covered with a sticker.
  
  . REQUIRED I hereby grant permission to St. Monica Parish to publish my child's name, photo, or video image in connection with a display, feature story or other publication as deemed appropriate by St. Monica Parish or the Diocese of Kalamazoo. Do not publish my child's name, photo, or video images Please fill out this field.
  
  General Release
  
  In consideration of my child being allowed to participate in faith formation and youth ministry programming, I agree to indemnify and hold harmless St. Monica Catholic Parish, and any and all affiliated organizations, their employees, agents, representatives, including volunteer and other drivers, from any and all claims, negligence, arising from or relating to my child’s participation in this program. This indemnification does not apply to claims for intentional misconduct or gross negligence.
  
  Parent/Guardian Initials REQUIRED Please fill out this field. Please enter valid data.
  
  Child Pick- Up After Programming
  
  Who may pick up your child(ren)? REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Info
  
  Emergency Contact Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Minor: REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED
  
  Please fill out this field. Please enter a phone number.
  
  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. I fully understand and agree to the above terms and sign this form knowingly, willingly and freely.
  
  If parent prefers to complete a paper copy of this release, please contact the Youth Minister at the parish.
  
  Parent/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

Saint Monica Catholic Church

Kalamazoo, mi

'26-'27 Middle School Youth Group Registration

2026-2027 Student Information

Family Information

Second Parent/Guardian Information (optional)