2013-2014 JUMMP High School Religious Education Registration Form

(Please print clearly. Fill out one form - both sides - for EACH high school student.)

Cost: $60 for students not getting confirmed; free for students currently going through confirmation program Please make checks payable to JUMMP and return by August 30th
(All fees will be split amongst the parishes according to the approximated percentage of students per parish).

Student Name: ___________________________________________ Cell Phone: ______________________ Address: _________________________________________________________________________________ City: ___________________________ State: __________________ ZIP: __________________

Students Email: ___________________________________________________________________________ Sex: Male Female Birthdate (Mo/Day/Yr): _______________ Grade: ____________________

School: __________________________________________________________ Parish: __________________________________________________________ Parents Names: ___________________________________________________________________________ Parents Email: ____________________________________________________________________________ Phone Number(s): Home ____________________________ Work __________________________________ Cell ______________________________________________________________________ MEDICAL INFORMATION Students allergies and/or medical condition(s): _________________________________________________ __________________________________________________________________________________________ INSURANCE INFORMATION: (Both lines MUST be completed.) Family Health Insurance Company: __________________________________________________________ Policy Number: ___________________________________________________________________________ MEDICATIONS: (continued on other side) If prescription and/or non-prescription medications are needed, please send them with your child and list these medications in the following section and include product name and physicians instructions on dosage and frequency. Any medications brought to the program should be clearly labeled and in their original container. MEDICATIONS: (continued)

1. ________________________________________________________________________________________ 2. ________________________________________________________________________________________ VACCINATIONS: All Vaccinations should be up-to-date, especially Tetanus booster. PARTICIPATION CONSENT: I grant permission for my child to participate in JUMMP Youth Ministry events. I will not hold the Archdiocese of Indianapolis, St. Joseph University Church, St. Margaret Mary Church, or St. Patrick Church responsible in the event of any injury or accident to my son or daughter while participating in JUMMP youth events, and/or traveling to and from these events. I warrant that, to the best of my knowledge, my child is in good health and able to participate in all program activities. (Please submit a statement indicating limitations and/or conditions of which we should be aware.) I agree that my child shall abide by the JUMMP Youth Ministry Code of Conduct. I have reviewed and discussed the Code with my child prior to signing this form. I agree that if my child fails to abide by the Code or engages in a serious infraction of the Code, he or she may be immediately dismissed from the youth event with no refund, and sent home at my expense. I understand that all medication will remain in the possession of the adult team leader (exception: inhaler) and be dispensed as prescribed. Please note that non-prescription medication (such as Tylenol, throat lozenges, cough syrup) will not be available to your child unless you provide them for your child. In case of medical emergency, I understand that every effort will be made to contact parents or guardian of participants. In the event that I cannot be reached, I hereby give permission to the Director of Youth Ministry to seek treatment for my son/daughter. I hereby give permission to the medical staff to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child.

If you cannot reach me in case of an emergency, please contact:

Name: ____________________________________________________ Phone: _________________________ Relation to student: __________________________________________ I give permission for my child to be photographed and/or videotaped ______ Yes _____ No Parent/Guardian Signature: _______________________________________ Date: _______________________ Name: (Printed) _______________________________________________ Phone: _______________________ Youth Participant: I understand and agree to the JUMMP Youth Ministry Code of Conduct. I also understand that my Parent or guardian will be notified at the time of any infractions requiring my dismissal from the program, and that I will be sent home at my own expense. Youth Signature: _____________________________________________ Date: ________________________ Return form & money to: Coordinator of Youth Ministry 1807 Poplar St. Terre Haute, IN 47803

You must have this form completed and signed to attend JUMMP Youth Events/Religious Education

JUMMP YOUTH MINISTRY CODE OF CONDUCT

To help insure that participants have a good, safe time, the following Code of Conduct will be in effect during all JUMMP youth events.

Parents and youth participants are to review this document and keep for their records.
1. Participants are expected to participate in assigned activities. 2. Dress is casual. Jeans, T-shirts, etc., are fine. Clothing with offensive or obscene words, pictures, symbols, etc. is not acceptable. Shirts must be worn at all times. No halter tops, tank tops or sleeveless shirts are allowed. Shorts/skirt length must be appropriate (when a person is standing straight with arms hanging to side, shorts must meet or pass their fingertips). Pants must not sag, or a belt will be provided. 3. Language and conduct should reflect the values we proclaim as Catholics. Participants must show respect to all adult leaders and peers at all times. Disrespect of each other and adult leaders will not be tolerated. 4. Participants are to remain with their group at all times during youth events unless otherwise directed by adult leaders. 5. Only the Director of Youth Ministry can alter plans/timing of any scheduled activity. 7. Smoking and the use of tobacco products is not allowed by any participants during any youth event. Violation of this rule will result in immediate dismissal from the event. 8. The possession or use of alcohol, illegal drugs or weapons will not be tolerated. Breaking this rule will mean immediate dismissal from the event. (Parents will be called, regardless of the hour.) 9. The use of cell phones/pagers is prohibited during catechesis classes, retreats, special presentations, etc. 10. Participants should not bring food and/or drinks unless otherwise directed by the adult leader(s).