| St. John Vianney Catholic Church

YDisciple Registration

Parent's Name REQUIRED Please fill out this field. Please enter valid data.

Parent's Email REQUIRED Please fill out this field. Please enter an email address.

Parent's Phone Number Please enter a phone number.

Parent Support Options:

What areas can you help with? Chaperoning at special events Planning special events Providing snacks

Permission and Liability Waiver

We, as parents/guardians of the minor(s) whom we are registering for St. John Vianney's YDisciple program for the 2023-2024 school year, hereby consent and agree to hold harmless St. John Vianney Parish and/or the Roman Catholic Diocese of Lafayette-in-Indiana, Inc., and any and all employees or volunteers thereof, for any accident, injury or occurrence arising out of, or in connection with the aforementioned activity.

I have read and understood the consent to hold harmless St. John Vianney Catholic Church and the Diocese of Lafayette-in-Indiana. REQUIRED Yes Please fill out this field.

I understand that photos of my child, may be used for parish media such as SJV's Facebook, SJV's Instagram, parish bulletin and website, as well as The Catholic Moment. No names will be used in any picture of your child. REQUIRED Yes Please fill out this field.

Other Medical Treatment: In the event it comes to the attention of the YDisciple Mentors, SJV staff, or representative that your child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, you will be called. If we are unable to contact you, the emergency contact person listed below will be contacted.

Emergency Contact Person (Other than the parent)

First Name: REQUIRED Please fill out this field. Please enter valid data.

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

Phone Number: REQUIRED Please fill out this field. Please enter valid data.

Youth Information

How many youth are you registering? REQUIRED Please fill out this field.
Youth: 1
- Youth's First Name: REQUIRED Please fill out this field. Please enter valid data.
- Youth's Birthday: (MM/DD/YY) REQUIRED Please fill out this field. Please enter valid data.
- Youth's Grade and Name of School: REQUIRED Please fill out this field. Please enter valid data.
- Does this youth have an Individualized Education Plan (I.E.P)? REQUIRED Yes No Please fill out this field.
- Please indicate below if this youth has any special considerations you would like us to know about. (special needs, significant life events, allergies, etc.)
Youth: 2
- Youth's First Name: REQUIRED Please fill out this field. Please enter valid data.
- Youth's Birthday: (MM/DD/YY) REQUIRED Please fill out this field. Please enter valid data.
- Youth's Grade and Name of School: REQUIRED Please fill out this field. Please enter valid data.
- Does this youth have an Individualized Education Plan (I.E.P)? REQUIRED Yes No Please fill out this field.
- Please indicate below if this youth has any special considerations you would like us to know about. (special needs, significant life events, allergies, etc.)
Youth: 3
- Youth's First Name: REQUIRED Please fill out this field. Please enter valid data.
- Youth's Birthday: (MM/DD/YY) REQUIRED Please fill out this field. Please enter valid data.
- Youth's Grade and Name of School: REQUIRED Please fill out this field. Please enter valid data.
- Does this youth have an Individualized Education Plan (I.E.P)? REQUIRED Yes No Please fill out this field.
- Please indicate below if this youth has any special considerations you would like us to know about. (special needs, significant life events, allergies, etc.)
Youth: 4
- Youth's First Name: REQUIRED Please fill out this field. Please enter valid data.
- Youth's Birthday: (MM/DD/YY) REQUIRED Please fill out this field. Please enter valid data.
- Youth's Grade and Name of School: REQUIRED Please fill out this field. Please enter valid data.
- Does this youth have an Individualized Education Plan (I.E.P)? REQUIRED Yes No Please fill out this field.
- Please indicate below if this youth has any special considerations you would like us to know about. (special needs, significant life events, allergies, etc.)

St. John Vianney
Catholic Church, Fishers, IN

A Pastorate of the Diocese of Lafayette-in-Indiana

YDisciple Registration

ST. JOHN VIANNEY CATHOLIC CHURCH