St. Mary of the Miraculous Medal High School Student Information Faith Formation Year 2014-2015 1604 9th Ave N Texas City, Texas 77590 (409) 948-8448 Sacraments Celebrated What is Life Teen? - As a Eucharist-centered movement within the First Eucharist Roman Catholic Church, Life Teen leads teenagers and their families into a deeper relationship with Jesus Christ and His Church. With the Blessed Virgin Mary as our intercessor and guide, Life Teen seeks to unleash the fullness of the Sacramental power present within the young Church. Reconciliation Who can attend Life Teen? - Any High School Student Please Circle all that Apply Baptism Confirmation Confirmation Year Confirmation Y1 Confirmation Y2 T-Shirt Adult sizes (Circle One) Small Medium (9th-12th grade) *Confirmation Preparation teens must register for Life Teen* Payment Information– The 2014-2015 Life Teen fee is $55 ($20 extra for Confirmation 2 -$75 total) per teen which includes a new Life Teen t-shirt. The fee helps offset the cost of textbooks, supplies, materials, food and speakers necessary to offer a high quality program. Please make checks payable to: St. Mary of the Miraculous Medal. Large XL 2XL 3XL No teen will be denied instruction for financial reasons. DATE RECEIVED AMOUNT OF CHECK CHECK # AMOUNT OF CASH ***PLEASE PRINT CLEARLY*** Student Name: _______________________ _______________________ ______________________________ First Middle Last __________________ Male/Female Address: ______________________________________________________________________________________________________ City State Zip Code Student Mobile: _(______)_________________________________ Mobile Provider : _________________ Text Okay? Yes No Student Email: __________________________________________________________________________________________________ Parent (Guardian) Name: _______________________________________ First Parent (Guardian) Parent (Guardian) Name: _______________________________________ Second Parent (Guardian) Home #: _(_____)________________________________ Mobile #: _(_____)_______________________________ Home #: _(_____)________________________________ Mobile #: _(_____)_______________________________ Provider: ____________________ Text Okay? Yes No Provider: ____________________ Text Okay? Yes No Email: _________________________________________ Email: _________________________________________ Permission to Communicate: Parent (Guardian) _____________________________ Student___________________________________ CONCENT & LIABILITY WAIVER Important! To be filed out by the Parent/Guardian for youth under 18 years of age. If participant is 18 years of age or older, consent must be signed by the individual. I (name of parent/guardian) ______________________________________, grand permission for my child., (participant’s name), _______________________________ to participate in LIFE TEEN LIFE NIGHTS or CONFIRMATION PREPRATION to be held on SELECTED SUNDAY NIGHTS AND SATURDAYS, (SUNDAYS) 6:00 PM TO 8:30 PM (SATURDAYS) 9AM TO 6:30PM) IN THE PONZINI FAMILY LIFE CENTER. I agree on behalf of myself, my child’s other parent if known or living (name of parent), ___________________________, my child named herein, or our here, successors, and assigns and defend the Archdiocese of Galveston-Houston, the sponsoring parish of St. Mary of the Miraculous Medal (its pastor, youth ministry leaders, principal, other agents, etc.) or any representatives associated with the scheduled activity unless the parties involved were careless and negligent. In signing this form I certify that all information contained herein is true and accurate to the best of my knowledge. _________________________________________________ Signature (Parent/Guardian) __________________ Date YOUTH PARTICIPANT: In signing the line below I agree to abide by any/all policies and rules established for this event/activity set by the youth ministry leader(s)/pastor. Should I not be able maintain the guidelines and expectations of the adults and my peers, I understand that there will be consequences for my actions, including being removed from the activity and being sent home at my parents expense. _________________________________________________ Signature (Youth Participant) __________________ Date Media Release Permiso de medios publicitarios I (do / do not ) grant permission to St. Mary of the Miraculous Medal Church in Texas City, Texas to allow my child, to be photographed. It is my understanding that the photograph may be used for public view during the 2014-2015. School year. Yo (si / No) doy mi permiso a Santa Maria de la Medalla Milagrosa en Texas City, de tomar fotos de mi niño. Yo entiendo que las fotografías se pueden usar para el público durante el año 2014-2015. I understand that granting permission releases St. Mary of the Miraculous Medal Church and the Archdiocese of GalvestonHouston from any future claims as well as any liability arising from the use of said photograph. Yo entiendo que al dar permiso no tengo derecho a demandar o culpar a Santa Maria de la Medalla Milagrosa de la Arquidiócesis de Galveston – Houston por si algún problema ocurre por el uso de fotografías. ________________________________________ Parent / Guardian Signature Firma del padre/guardián ________________________________ Date / Fecha