Lifeteen Registration Registration for LIFETEEN School Year 2020-2021 Teen Name First Last Teen NicknameIf Teen goes by different name than mentioned above. Grade (2020-2021)*9101112Contact InformationCell 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?*YesNoTeen Cell Phone*Can St. James Youth Ministry "follow" your teen on social media?*YesNoInstagram HandleFollow St. James Youth Ministry (@stjameslt) and St. James Parish (@stjamesah)Sacrament InformationHave you been Baptized?*YesNoHave you received your First Holy Communion?*YesNoHave you been Confirmed?*YesNoParent Contact InformationParent/Guardian Name* First Last Parent/Guardian Email Address* Parent/Guardian Cell Phone*Family Mailing Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Second Parent/Guardian Name First Last Second Parent/Guardian Cell PhoneSecond Parent/Guardian Email Address In Case of EmergencyIf 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 MinistryOpen 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?YesNoPick Up ProcedureIn the event a parent is not available to pick up their child from Youth Ministry events, I authorize my child to:*Drive ThemselvesCarpool with a friendCarpool with a known parentWalk/Bike on their ownNone of the Above - Parent Pick Up ONLYPhoto/Media WaiverI 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 WaiverBy 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 & PaymentLIFETEEN Registration - Discounted Rate Price: $120.00 Quantity: LIFETEEN Registration - Regular Rate Price: $150.00 Quantity: Scholarship Code Total $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Security Code Cardholder Name This iframe contains the logic required to handle Ajax powered Gravity Forms.