Student Ministry Registration Fairfield LIFE TEEN + EDGE Registration/Waiver Parent / Guardian InformationParent / Guardian Name First Last Email*Please use an email address that the family checks regularly, as this is our primary means of communication Enter Email Confirm Email Phone*Please provide a cell phone number that can be reached in the event of inclement weather or last minute cancellationsEmergency Contact* First Last Emergency Contact Phone*Please provide a cell phone number that can be reached in the event of inclement weather or last minute cancellationsAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Which parish is your family registered at?*Assumption (Fairfield, CT)St. Thomas Aquinas (Fairfield, CT)St. Pius X (Fairfield, CT)OtherPlease type in the name of your parishStudent(s) InformationParticipating Members*Click the "+" symbol to add multiple students. All text-messages are sent through FLOCKNOTE. A safe-environment approved software where personal numbers are never disclosed or shared. Messages sent will be used for reminders or cancellations. StudentBirthdateGenderGradeProgramEmailMobile for TXT Updates MF6789101112EDGE (Gr. 6-8)LIFE TEEN (Gr. 9-12) Student Health Insurance Information*Please list your Health Insurance Provider, Policy #, Group # and Health Insurance Phone #.StudentHealth InsurancePolicy #Group # Health Insurance Phone #Student Allergy/Medical DisclosurePlease let us know if your child has any allergies (medical or food related) or any medical/behavioral conditions that we should know about. Please list current and past medical information that may be pertinent to proper medical care.StudentFood AllergiesMedical AllergiesAny Additional Medical/Behavioral Conditions Authorize ConsentParent / Guardian Consent*I. I hereby give permission for my child(ren) to attend and participate in activities sponsored by the Fairfield LIFE TEEN + Fairfield EDGE Programs. II. I authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any licensed physician or dentist. I shall be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered. III. I hereby grant permission for non-prescription medication to be given, if deemed appropriate. IV. Should it be necessary for my child(ren) to return home due to medical reasons, behavioral reasons, or otherwise, I shall assume all transportation costs. V. I also give permission for my child(ren) to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by the Fairfield LIFE TEEN + Fairfield EDGE Programs, provided that vehicle has at least 2 VIRTUS trained adults. I agree to the statement above Code of Conduct*I understand that by requesting my child(ren) to attend/participate in Fairfield LIFE TEEN + Fairfield EDGE events, trips, and activities, they are to cooperate with the youth ministers, church staff, priests, CORE members, and other youth throughout the trip. Students are to follow all instructions and rules. Smoking at any youth events/trips is not allowed. Bringing or using any illegal drugs or alcohol is prohibited. In the event that your child(ren) fail to obey the guidelines set forth above, I understand that my child(ren) will be sent home at my family’s expense. I agree to the statement above Permission to Photograph*** Fairfield LIFE TEEN + EDGE may use pictures containing families, including minors, for the sole purpose of promoting our program here at St. Pius X, St. Thomas Aquinas, or Assumption Parish in Fairfield, CT in the weekly bulletin, parish website, Facebook and Instagram (@fairfieldlt), newsletters or articles that may appear in the Fairfield County Catholic (the Diocesan newspaper). News Releases will never contain last names of any minors. Addresses and phone numbers will never be released in such publications. This agreement will be considered active and ongoing unless it is cancelled, in writing, by the individual or their parent/guardian. I give permission for Fairfield Life Teen +EDGE to photograph my family and my children. These photos can be used in the above-named news releases from this day forward unless this agreement is cancelled per my request. I agree to the statement above THE DIOCESE OF BRIDGEPORT: Permission Form for Direct Electronic Communication with Minors* NAME OF PARISH/ORGANIZATION: Fairfield LIFE TEEN + Fairfield EDGE in FAIRFIELD, CT In the Diocese of Bridgeport, parents and/or legal guardians will be copied into all electronic communications except those that occur on an official social networking site or online community administered and maintained by the Diocese, Parish, or School pursuant to the terms of diocesan policy and any additional forms of communication as approved by parents or guardians on this form. This form allows a parent or legal guardian to specifically authorize adult emergency contacts and other adults within their parish or organization to communicate through electronic means directly with a minor child. These communications may be conducted through personally owned cellular phones or personally owned computers that are not purchased, operated or monitored by the Parish or by the Diocese of Bridgeport. I agree to the statement above Authorized Adults to Communicate with MinorsPlease list the name of adults who can personally contact your child (ren) through their own personal cell phone or computer. This form allows a parent or legal guardian to specifically authorize adult emergency contacts and other adults within their parish or organization to communicate through electronic means directly with a minor child.Name of AdultEmailPhone NameThis field is for validation purposes and should be left unchanged.