Edge and Life Teen Registration Family Name*Primary Family e-mail* Father’s Full Name* First Last Virtus Trained*YesNoMother’s Full Name* First Last Virtus Trained*YesNoMother’s Maiden Name* Last Address* Street Address City State ZIP Code Home Phone*Cell Phone*Student InformationStudent’s Full Name* First Last Full Date of Birth* MM DD YYYY Gender*MaleFemaleAge*Adult T-Shirt SizeX-SmallSmallMediumLargeX-LargeSchool 2014/2015*Entering Grade*Student’s Cell Phone*Student’s e-mail Sacramental HistoryGive date, church, city and state for each sacrament received.Baptism1st EucharistConfirmationIs the student enrolling in Confirmation preparation this year?*YesNoIf yes please see the additional Confirmation preparation information.List any allergies, health concerns or special needs that would give our catechists the appropriate support to teach your child:*RELEASE OF LIABILITY AND MEDICAL RELEASEChild’s Full Name* First Middle Last Parent(s)/Guardian’s NamesAddress Street Address City State ZIP Code Home PhoneCell PhoneEmergency Contact Name (other than parents)Contact NumberRelationship to ChildDoes your child have allergies?YesNoDetailsIs your child taking any medication?YesNoDetailsAre there any physical or emotional conditions of which we should aware?YesNoDetailsAs parent and/or legal guardian I remain legally responsible for any personal actions taken by the above named minor. I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St. Nicholas Catholic Church, and the Catholic Diocese of Richmond, its employees and agents, chaperons, or representatives associated with St. Nicholas Youth Ministry from any claim arising from or in connection with my child attending St. Nicholas youth events or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate St. Nicholas, the Diocese, its employees and agents and chaperons, or representatives associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the Diocese. I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. In the event of any emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers I give permission for the noted emergency contact to be notified. I will not hold St. Nicholas Catholic Church, and/or the Diocese of Richmond responsible for authorizing any medical treatment beyond necessary transportation to the hospital. Parent / Guardian Signature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I give permission for pictures and / or video of my child (named above) engaged in activities related to the Parish or Diocesan events to be posted in St Nicholas Catholic Church publication, websites or other social media. If no box is checked below, the Church of Saint Nicholas assumes you give permission.*YesNoParent / Guardian Signature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920