Lifeteen Registration | Saint James Parish

Teen Name

First Last

Teen Nickname

If Teen goes by different name than mentioned above.

Grade (2020-2021)*

Contact Information

Cell phone and email communication will only be used by LIFETEEN Youth Ministers and Core Members to share youth ministry information, for invitations to youth ministry activities and events, and for LIFETEEN related messages.

Teen Email Address*

Can we send teen cell phone text messages?*

Yes
No

Teen Cell Phone*

Can St. James Youth Ministry "follow" your teen on social media?*

Yes
No

Instagram Handle

Follow St. James Youth Ministry (@stjameslt) and St. James Parish (@stjamesah)

Sacrament Information

Have you been Baptized?*

Yes
No

Have you received your First Holy Communion?*

Yes
No

Have you been Confirmed?*

Yes
No

Parent Contact Information

Parent/Guardian Name*

First Last

Parent/Guardian Email Address*

Parent/Guardian Cell Phone*

Family Mailing Address*

Street Address Address Line 2 City State ZIP Code

Second Parent/Guardian Name

First Last

Second Parent/Guardian Cell Phone

Second Parent/Guardian Email Address

In Case of Emergency

If the parents or guardians cannot be contacted in case of serious injury or illness, I authorize St. James Staff to take emergency action deemed necessary, including the transportation of the student to a hospital or medical center. As a parent or guardian, I authorize the treatment by a qualified and licensed medical doctor of the minor(s) listed in this registration in the event of a medical emergency that, in the opinion of the attending physician, may endanger his/her life, cause disfigurement or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.

Emergency Contact Name*

Other than parent/guardian

First Last

Emergency Contact Relationship to Teen*

Emergency Contact Cell Phone*

Emergency Contacts will be contacted after attempts have been made to contact parent/guardian(s) listed above.

Open Doors Ministry

Open Doors Ministry is here to help support all families and ensure every child has access to faith formation in a peer setting. By voluntarily answering this question you are helping us provide an appropriate classroom environment for all students. This information will be kept confidential.

Does your child have a special need that requires adaptive programming or a one-on-one mentor in the classroom?

Yes
No

Pick Up Procedure

In the event a parent is not available to pick up their child from Youth Ministry events, I authorize my child to:*

Photo/Media Waiver

I hereby authorize and give my full consent to St. James Parish the use of my child(ren)’s image (photographs, video, and/or audio) and further agree that St. Jams Parish may use these photographs, video or audio files for promotional materials.

Liability Waiver

By completing this registration, I hereby give permission to my son/daughter, mentioned above, to participate in LIFETEEN activities sponsored by St. James. I hereby release and indemnify the Archdiocese of Chicago, St. James for this event, its staff and volunteers; and the Catholic Bishop of Chicago, a corporation sole, from any and all liability arising from claims of any kind or nature whatsoever from my child’s participation in the program. I understand that if my child violates any laws regarding possession of alcohol or drugs, or rules governing the event, I will be called and notified about situation and/or arrangements made to send my child home at my expense.

Terms & Conditions*

I have read and agree to terms and conditions in the following sections of this registration: Liability Waiver, In Case of Emergency, and Media/Photo Waiver.

Parent/Guardian Electronic Signature*

Registration Fees & Payment

LIFETEEN Registration - Discounted Rate

Price: $120.00 Quantity:

LIFETEEN Registration - Regular Rate

Price: $150.00 Quantity:

Scholarship Code

Total

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name