OLQP PRISM Youth Ministry Registration 2023-2024

OLQP PRISM Youth Ministry Registration 2023-2024

This registration form is for OLQP's Youth Ministry, for 7th-12th grade students. Please visit the Youth Ministry page for more information and updates on activities and events:https://www.ourladyqueenofpeace.org/youth--young-adult.html

Please contact Rebecca Grant Jenkins for questions: rgrantjenkins@olqpva.org

PLEASE NOTE: This is NOT the parish registration form. Parish registration not required; If registering for the parish go to: http://www.ourladyqueenofpeace.org/register.html. Click on "Register with Us!"

Please be sure to complete all pertinent sections and click submit at the bottom. Thanks.

Teen 1 Name Teen 1 Name First Last
Nickname
Teen 1 Cell Number
Teen 1 Email Address
Teen 1 Date of Birth Teen 1 Date of Birth / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Teen 1 School Name (2021-2022)
Teen 1 Grade (2021-2022)
Teen 1 - Medical/Dietary/Personal Information the youth minister should know about in order to best serve your teen (This information is confidential)?
Teen 2 Name Teen 2 Name First Last
Nickname
Teen 2 Cell Number
Teen 2 Email Address
Teen 2 Date of Birth Teen 2 Date of Birth / MM / DD YYYY
Teen 2 School Name (2021-2022)
Teen 2 Grade in School (2021-2022)
Teen 2 - Medical/Dietary/Personal Information the youth minister should know about in order to best serve your teen (This information is confidential)?
Teen 3 Name Teen 3 Name First Last
Nickname
Teen 3 Cell Number
Teen 3 Email Address
Teen 3 Date of Birth Teen 3 Date of Birth / MM / DD YYYY
Teen 3 School Name (2021-2022)
Teen 3 Grade in School (2021-2022)
Teen 3 - Medical/Dietary/Personal Information the youth minister should know about in order to best serve your teen (This information is confidential)?
Parent/Guardian 1 Parent/Guardian 1 First Last
Parent Guardian 1 Cell Phone Parent Guardian 1 Cell Phone - ### - ### ####
Parent/Guardian 1 Email
Parent/Guardian 2 Parent/Guardian 2 First Last
Parent/Guardian 2 Cell Phone Parent/Guardian 2 Cell Phone - ### - ### ####
Parent/Guardian 2 Email
It is strongly encouraged that at least one parent participate in at least one activity or event during the program year. Diocesan child & youth safety compliance required. Please check areas of interest:

It is strongly encouraged that at least one parent participate in at least one activity or event during the program year. Diocesan child & youth safety compliance required. Please check areas of interest: Weekly Teen Nights, Sundays, 7:00pm - 8:00pm Firepit Fridays (scheduled 1-2 Monthly) Teen Night/Fire Pit Friday Dinner & Dessert for 15 Special Events (onsite/offsite-Friendsgiving, Retreats (on-site/off-site), Diocesan events Work Camps (CHWC - 10th-12th+)/YDWC (Rising 7th - 9th) Coordinate a monthly service activity (gleaning, car wash, fundraiser) Other Other
Emergency Contact Name
Emergency Contact Phone Number
Emergency Contact Relationship to Teen
MEDICAL RELEASE: I agree to indemnify Our Lady Queen of Peace Church, Youth Ministers, Volunteers and the Diocese of Arlington for any costs or expenses arising out of my child’s participation in parish and/or religious education activities, including the cost of any medical care given my child or any expenses or fees incurred in any law suit arising as a result of any damage or injuries caused by my child in the course of his/her participation in the activity.

I further give my consent to that in my absence the above named minor be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor.

MEDICAL RELEASE: I agree to indemnify Our Lady Queen of Peace Church, Youth Ministers, Volunteers and the Diocese of Arlington for any costs or expenses arising out of my child’s participation in parish and/or religious education activities, including the cost of any medical care given my child or any expenses or fees incurred in any law suit arising as a result of any damage or injuries caused by my child in the course of his/her participation in the activity.

I further give my consent to that in my absence the above named minor be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor. Accept
CATHOLIC DIOCESE OF ARLINGTON PHOTO, PRESS, AUDIO AND ELECTRONIC MEDIA RELEASE
I AUTHORIZE THE Catholic Diocese of Arlington, its parishes and/or schools to use and publish the photographs and/or motion picture of videotape for which my child has posed, and/or audio recordings made of his/her voice. I agree that the Catholic Diocese of Arlington, its parishes and/or schools may use such photographs of my child with or without his/her name and for any lawful purpose, including, for example, such purposes as publicity, illustration, bulletin and Web content.

CATHOLIC DIOCESE OF ARLINGTON PHOTO, PRESS, AUDIO AND ELECTRONIC MEDIA RELEASE
I AUTHORIZE THE Catholic Diocese of Arlington, its parishes and/or schools to use and publish the photographs and/or motion picture of videotape for which my child has posed, and/or audio recordings made of his/her voice. I agree that the Catholic Diocese of Arlington, its parishes and/or schools may use such photographs of my child with or without his/her name and for any lawful purpose, including, for example, such purposes as publicity, illustration, bulletin and Web content. I give my consent I do not give my consent