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The EDGE Registration Form We will be communicating by e-mail whenever possible
YOUTH’S FULL NAME__________________________________________ BIRTH DATE GENDER GRADE T-SHIRT SIZE (Adult) _________________ SCHOOL _____________________________________________________ YOUTH’S E-MAIL ADDRESS ____________________________________
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Family’s Last Name ________________ Address _________________________ Father’s Full Name _________________ Father’s Work Phone _______________
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Home Phone Number _______________ City, State, ZIP ____________________ Mother’s Full Name ________________ Mother’s Work Phone ______________
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Parents’ e-mail address ___________________________________________
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$15 ____ $20 ____ $25 _____ Other
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Annual Fees $35 per Child - - $20 for additional sibling Amount Paid $________ Check # ________ Cash ______ NO MIDDLE SCHOOLER IS EVER TURNED AWAY FOR LACK OF FUNDS Please contact Ricky Busha Deadline by September 4, 2005 Please complete additional registration information on the back of this form
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The information below is confidential Does your child have any special needs due to a learning disability, physical disability, reading difficulty, hearing impairment, emotional problem, or any other reason? Special Need ___________________________________________________
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Does this child take any medications? Yes No |
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Describe any allergy, chronic illness or other conditions: ____________________
If yes, list: ______________________________________________________ My child has no special needs ______________________ In case of emergency, please contact: _________________ Phone______________
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Check the appropriate box ONLY if the statement applies Yes No Middle School Youth has been baptized………………………......... Middle School Youth has made First Communi……………………... I/We would like to discuss baptism and/or sacrament preparation for our middle school youth ..................................................................................Registered at Holy Cross Church…………………………………....
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MODEL RELEASE STATEMENT I hereby grant permission for my child to be photographed and/or videotaped during EDGE Activities and events. I understand that my child may decline to be photographed and/or videotaped at any time. I further grant permission for the resulting photographs and/or videotaped footage to be edited, if necessary, and then published and/or broadcast for the purpose of promoting the EDGE and/or youth programs at Holy Cross Church. Name (PLEASE PRINT) ___________________________________________(SIGNATURE) (DATE)___________________________________________ |
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I hereby decline to grant permission for my child to be photographed and/or videotaped during EDGE activities and events. I have instructed my child to decline to be photographed and/or videotaped at all times. I have further instructed my child to notify EDGE coordinators and/or Core Team Members that he/she may not be photographed and or videotaped under any circumstances. Name (PLEASE PRINT) ___________________________________________(SIGNATURE) (DATE)___________________________________________ |
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