CYM Registration Form 2016-2017

St. Luke's Parish Catholic Youth Ministry Registration Form

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Family Last Name *
Home Address Home Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Best Contact Phone Best Contact Phone * - ### - ### ####
Home/Family Email *
Parent's Information

Please answer the following questions: *
Please answer the following questions:	Yes	No
Are you interested in participating in the Adult Core Team?	Are you interested in participating in the Adult Core Team?Yes	Are you interested in participating in the Adult Core Team?No
Have you had a Diocesan background check?	Have you had a Diocesan background check?Yes	Have you had a Diocesan background check?No
Have you taken "Protecting God's Children"? (Log on to Virtus.org to register)	Have you taken "Protecting God's Children"? (Log on to Virtus.org to register)Yes	Have you taken "Protecting God's Children"? (Log on to Virtus.org to register)No

Father's Name Father's Name First Last
Father's Cell Phone Father's Cell Phone - ### - ### ####
Mother's Name Mother's Name First Last
Mother's Cell Phone Mother's Cell Phone - ### - ### ####
Emergency Contact Information

In the event of an emergency, if you are unable to reach me at the above number, contact:
Name & Relationship *
Phone Phone * - ### - ### ####
Family Doctor
Phone Phone - ### - ### ####
Family Health Plan Carrier
Policy Number