H.S. Summer Youth Mission Days 2022&lt;div&gt;Serve This City!&lt;/div&gt;

This is the online permission form H.S. teens who wish to participate in the H.S. Summer Youth Mission Days 2022 which will take place on Monday, June 20 to Wednesday, June 22, 2022 from 8:30 a.m.-4 p.m.

Please complete the form below.

Family Last Name REQUIRED Please fill out this field. Please enter valid data.

Father's Name Please enter valid data.

Mother's Name Please enter valid data.

Street Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Home Phone Number Please enter a phone number.

Dad's Cell Phone Number Please enter a phone number.

Mom's Cell Phone Number Please enter a phone number.

Primary Email REQUIRED Please fill out this field. Please enter an email address.

Are you a registered member of Good Shepherd? REQUIRED Yes No Please fill out this field.

How many teens would you like to register for the H.S. Summer Youth Mission Days 2022? REQUIRED Please fill out this field.
Name of Teen Participant 1
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Grade Level (as of fall of 2021) REQUIRED Please fill out this field. Please enter an integer (number).
- Sex
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- My teen is able to participate with the H.S. Summer Youth Mission Days 2022 on the following days: REQUIRED Monday, June 20, 2022 (8:30 a.m.-4 p.m.)
  at Matthew 25 Ministries Tuesday, June 21, 2022 (8:30 a.m.-4 p.m.)
  at Children's Home of Cincinnati Wednesday, June 22, 2022 (8:30 a.m.-4 p.m.)
  at St. Leo's Parish Please fill out this field.
- Fee per person -20.0
- Please list allergies (e.g. food, drugs, anesthetics). If this does not apply, please write "NA." REQUIRED Please fill out this field.
- Please list medications taken regularly. If this does not apply, please write "NA." REQUIRED Please fill out this field.
- Please list any conditions/impairments (e.g. epilepsy, diabetes, asthma). If this does not apply, please write "NA." REQUIRED Please fill out this field.
Name of Teen Participant 2
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Grade Level (as of fall of 2021) REQUIRED Please fill out this field. Please enter an integer (number).
- Sex
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- My teen is able to participate with the H.S. Summer Youth Mission Days 2022 on the following days: REQUIRED Monday, June 20, 2022 (8:30 a.m.-4 p.m.)
  at Matthew 25 Ministries Tuesday, June 21, 2022 (8:30 a.m.-4 p.m.)
  at Children's Home of Cincinnati Wednesday, June 22, 2022 (8:30 a.m.-4 p.m.)
  at St. Leo's Parish Please fill out this field.
- Fee per person -20.0
- Please list allergies (e.g. food, drugs, anesthetics). If this does not apply, please write "NA." REQUIRED Please fill out this field.
- Please list medications taken regularly. If this does not apply, please write "NA." REQUIRED Please fill out this field.
- Please list any conditions/impairments (e.g. epilepsy, diabetes, asthma). If this does not apply, please write "NA." REQUIRED Please fill out this field.
Name of Teen Participant 3
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Grade Level (as of fall of 2021) REQUIRED Please fill out this field. Please enter an integer (number).
- Sex
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- My teen is able to participate with the H.S. Summer Youth Mission Days 2022 on the following days: REQUIRED Monday, June 20, 2022 (8:30 a.m.-4 p.m.)
  at Matthew 25 Ministries Tuesday, June 21, 2022 (8:30 a.m.-4 p.m.)
  at Children's Home of Cincinnati Wednesday, June 22, 2022 (8:30 a.m.-4 p.m.)
  at St. Leo's Parish Please fill out this field.
- Fee per person -20.0
- Please list allergies (e.g. food, drugs, anesthetics). If this does not apply, please write "NA." REQUIRED Please fill out this field.
- Please list medications taken regularly. If this does not apply, please write "NA." REQUIRED Please fill out this field.
- Please list any conditions/impairments (e.g. epilepsy, diabetes, asthma). If this does not apply, please write "NA." REQUIRED Please fill out this field.
Name of Teen Participant 4
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Grade Level (as of fall of 2021) REQUIRED Please fill out this field. Please enter an integer (number).
- Sex
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- My teen is able to participate with the H.S. Summer Youth Mission Days 2022 on the following days: REQUIRED Monday, June 20, 2022 (8:30 a.m.-4 p.m.)
  at Matthew 25 Ministries Tuesday, June 21, 2022 (8:30 a.m.-4 p.m.)
  at Children's Home of Cincinnati Wednesday, June 22, 2022 (8:30 a.m.-4 p.m.)
  at St. Leo's Parish Please fill out this field.
- Fee per person -20.0
- Please list allergies (e.g. food, drugs, anesthetics). If this does not apply, please write "NA." REQUIRED Please fill out this field.
- Please list medications taken regularly. If this does not apply, please write "NA." REQUIRED Please fill out this field.
- Please list any conditions/impairments (e.g. epilepsy, diabetes, asthma). If this does not apply, please write "NA." REQUIRED Please fill out this field.

FAMILY DOCTOR

What is the name of your family doctor? REQUIRED Please fill out this field. Please enter valid data.

Phone number for your family doctor. REQUIRED Please fill out this field. Please enter valid data.

#1 EMERGENCY CONTACT

List Emergency Contact (other than parents).

First Name Please enter valid data.

Last Name Please enter valid data.

Relationship Please enter valid data.

Phone Number Please enter a phone number.

#2 EMERGENCY CONTACT

List Emergency Contact (other than parents).

First Name Please enter valid data.

Last Name Please enter valid data.

Relationship Please enter valid data.

Phone Number Please enter a phone number.

ARCHDIOCESE OF CINCINNATI YOUTH
PERMISSION FORM FOR H.S. SUMMER YOUTH MISSION DAYS 2022 (Mon., June 20-Wed., June 22, 2022).

Please download, read and retain the Archdiocese of Cincinnati Permission, Release and Authorization to Seek Medical Treatment form ►

I have read and agree to the Archdiocese of Cincinnati Permission, Release and Authorization to Seek Medical Treatment form that has been provided in the block above. REQUIRED Yes No Please fill out this field.

PHOTO PERMISSION
I understand that Good Shepherd’s staff/ministry volunteers may take photos and videos during activities for the purpose of promoting the programs via our website, Sunday bulletin, parish social media page (for example, Facebook, Twitter, Instagram), or news releases to local or diocesan papers. I give my permission for pictures that are taken of my family, adults and children, to be used for this purpose.

I have read and agree to the Photo Permission statement listed above. REQUIRED Yes No Please fill out this field.

Please be aware that we will continue to follow the guidelines of the Archdiocese of Cincinnati regarding social distancing and other precautions due to the COVID-19 pandemic. We appreciate your patience and flexibility in the event changes in the pandemic leads to restructuring of program dates/classroom capacities.

I have read and understand that we are following all Archdiocesan Guidelines related to the pandemic, and if changes occur with the pandemic we will adjust accordingly. REQUIRED Yes, I have read and agree to the statement above regarding the pandemic. Please fill out this field.

By clicking on the "I Agree" box, it will serve as your digital signature for this submission.

I Agree Please select this field.

If you would like to share any additional information, please do so in the box below.

Name of Custodial Parent/Legal Guardian REQUIRED Please fill out this field. Please enter valid data.

Please type your initials below. REQUIRED Please fill out this field. Please enter valid data.

Today's Date REQUIRED Please fill out this field. Please enter a date.

H.S. Summer Youth Mission Days 2022
Serve This City!

H.S. Summer Youth Mission Days 2022 Flyer Download

Staff Contact

Permission Form for H.S. Summer
Youth Mission Days 2022

H.S. Summer Youth Mission Days 2022Serve This City!

H.S. Summer Youth Mission Days 2022
Serve This City!