Youth Information

Last Name ____________________

First Name ___________________

  Parish ______________________

  School ______________________

  Gender (circle)   M    F

  Grade (circle)

 EDGE   6  7  8

           Life Teen  9  10  11  12

 Birthday _____________________

Best way to reach your teen? ________

 Adult T – shirt size _____________

 Sports and activities involved in

_____________________________

_____________________________

Food Allergies ________________

Baptized Catholic                Yes   No  
Completed First Eucharist   Yes  No
Received  First Eucharist     Yes   No
Confirmed                           Yes   No

Family Information

Father’s Name _____________________ 

Mother’s Name ____________________

 Address __________________________

 City __________________Zip_______

 Home Phone Number _______________ 

Father’s Cell Phone __________________

 Mother’s Cell Phone ________________

 Father’s  Email _____________________

 Mother’s Email ____________________

 Preferred communication? ____________

 ________________________________

 Special Needs Information:  Does your child have special needs or challenges you would like us to know about that may require special attention by the program director or volunteer catechist (e.g. learning disability, classroom difficulties, medical condition, allergy, etc.)? _______________________________
_______________________________
_______________________________

Consent & Waiver:

From time to time, our Life Teen/Edge (LTE) member photographs, videos, voice recordings and/or work samples maybe selected for publication in/on our parish/diocese/school related print materials and websites. No personal information will appear with photos, videos, or recordings. LTE members may only be identified by grade or other group name.  Any photo, videos or samples of member work will appear with a notice prohibiting copying without express permission from the parents/guardians/or LTE Leader.  I hereby consent to the use of photos, video, voice recordings or work of my child to be published via print, video, or website which is affiliated with our LTE program. I understand that publication may be accomplished electronically via the Internet/World Wide Web and that after publication our LTE group will be unable to prevent persons from gaining access to the Internet/World Wide Web, copying my photographs and video, and subsequently using, altering, or republishing it without my consent. I waive any claim for damages from the unauthorized use, alteration, or republication of my photographs and video by third parties accessing the Internet/World Wide Web or obtaining copies of the print or video material.

 Signature_______________________Date________
      (or signature of Legal Guardian if under age 18)

 Waiver collected by (Printed): _________________

Waiver collected by (Signature): ________________