ST.

ROCCO YOUTH GROUP APPLICATION

Name: _______________________ _______________________ ____

Last First MI
Address: __________________ __________________________ ________
Street address City Zip code

Home phone: ( ) _________________Cell phone :( ) _____________

Email address: ________________________________________
Grade 2009-2010: ______ School: ________________________________
Birthday: _____ / _____ / _____
Parent/Guardian Information
Name: _______________________________ ___________________ _____
Last First MI
Address: __________________ ___________________________ ________
Street address City Zip code
Home phone: ( ) __________________Cell phone :( ) _____________
Please list any interests:
______________________________________________________________
______________________________________________________________
______________________________________________________________
What do you hope to get out of the St. Rocco Youth Group?
______________________________________________________________
______________________________________________________________
______________________________________________________________
How would you like to help?
______________________________________________________________
______________________________________________________________
______________________________________________________________
Please list any additional clubs you are involved with
______________________________________________________________
______________________________________________________________
 Parental Consent Form (please fill one or both)
Parent/Guardian 1 Parent/Guardian 2 or another
Name: emergency contact
Name:

_____________________________ _____________________________

Daytime: ( ) _________________ Daytime: ( ) __________________

Evening: ( ) _________________ Evening: ( ) __________________
Cell: ( ) _________________ Cell: ( ) __________________