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Antioch Life Teen

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					                                                             Antioch Life Teen                                  at St. Bernadette’s & Nativity of Our Lord Parishes

	                                      Event(s):	         Antioch Life Teen 2011 - 2012                          If electing to use Life Teen
	                                    Date/Time:	          Sundays / 7:35 - 9:05 PM                                   for Faith Formation,
	                                               	         September 2011 - May 2012                              Return this form with $50
                                                                                                                  to the Faith Form. Office
	                           Drop-off/Pick-up at:	         Nativity of Our Lord
	                  Supervision & Transportation:	         Youth Minister, Life Teen Core Group Adults, Other Parents and Adults
 
                                  Location(s):
         Nativity’s Parish Center, Cafeteria, Gym, Other as Announced



                   Name:	_________________________	 Teen Email:	 _________________________
Participant Info




                    Home Phone:____________________	 Teen Cell Phone:	 _____________________
                                                                                           Cellular Provider:	
 Verizon   AT&T   Sprint    T-Mobile   Virgin

                    Medical Info / Allergies:	________________________________________________


                   Name(s):	_______________________	 Parent Email:	________________________
Emergency




                   Home Phone:	 ___________________	 Parent Cell Phone:	____________________
                       If different from Participant Home Phone                            Cellular Provider:	
 Verizon   AT&T   Sprint    T-Mobile   Virgin

                The undersigned do hereby release, forever discharge and agree to hold harmless The Diocese of Buffalo, Nativity of Our Lord
                   Release
                Parish, St. Bernadette’s Parish, and Life Teen from and against any and all liability, claims, demands, lawsuits and expenses of any
kind whatsoever which may be incurred or suffered by the undersigned and/or participant (if participant is 18 or under, 18 or older) while attending
Antioch Life Teen Weekly Meetings.
The undersigned further agree to indemnify and hold The Diocese of Buffalo, Nativity of Our Lord and St. Bernadette’s Parishes, Life Teen and its
respective member, directors, employees, volunteers and agents (collectively, the “Indemnities,”) harmless from and against any and all claims,
demands, actions, lawsuits, and liabilities, including attorney fees and expenses and costs sustained by the Indemnities as a result of negligent, willful
or intentional acts of the undersigned and/or participant (if participant is 18 or under, 18 or older).
                  I hereby give permission to Nativity of Our Lord and St. Bernadette’s Parishes, Life Teen and its respective staff and adult volunteers
        Medical Care
                  to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not limited to emergency surgery
and I (we) fully and completely assume all responsibility for all medical bills. Further, should it be necessary for the participant to return home due to
medical reasons, disciplinary action or otherwise, I (we) assume all responsibility and transportation costs. This authorization also permits my youth to
receive such treatment only after such a reasonable effort has been made to reach me. Further, should it be necessary for all participants to return home
due to medical reasons, disciplinary action or otherwise, I (we) assume all responsibility and transportation costs.
            Permission          In signing this I am granting my youth permission to participate in Antioch Life Teen Weekly Meetings hosted by St. Bernadette’s
                                and Nativity Parishes. As well I am aware of the rules and responsibilities that my son/daughter is expected to uphold and respect.
        Photography             I understand my son/daughter’s photograph and/or likeness and name may be used in a future promotion by Nativity of Our Lord and
                                St. Bernadette’s Parishes and Life Teen whether that be a parish publication, website, or video publication.


                       Youth Signature:	 ______________________________Date:	 ______________
                       Parent Signature:	______________________________Date:	 ______________

                                                                                                                                          More on
                             If you have any questions, call Pat at 508-0258, or e-mail antiochlifeteen@gmail.com.                        Reverse
                                             Antioch Life Teen
                                               Information Sheet
                                                                                                                                               This  year  we’re  asking  for  
                                                                                                                                                your  cellular  provider,  
                                                                                                                                             hopefully  this  will  allow  us  to  
                                                                                                                                               keep  you  informed  about  
                                                                                                                                                 upcoming  events  and  
                                                                                                                                              deadlines  by  text  message!


                   Teen Name:_________________________Date of Birth: ______________________________

                   School: ____________________________Grade:____________________________________

                   Parish:_____________________________Are you coming for Religious Ed? Yes / No
Participant Info




                                                                                      Circle “Yes” if using Life Teen in place of class...          Circle One
                   Teen Email: __________________________________________________________________

                   Home Phone: _______________________Teen Cell Phone: ___________________________
                                                                                      Cellular Provider:    Verizon    AT&T      Sprint      T-Mobile      Virgin
                   Address: ___________________________
                           Number & Street
                                                       Social Network(s): Facebook                                                        MySpace Twitter
                   __________________________________ Cicle any that you use
                   City, State, Zip



                   Fall Sport(s): _________________________Fall Activities: ____________________________
Activities




                   Spring Sport(s):_______________________Spring Activities: __________________________


                   Parent Name(s): _____________________________/_________________________________

                   Parent Email(s): _____________________________/_________________________________
Parent Info




                   Parent Cell Phone(s): _________________________/ _________________________________
                     Cellular Provider(s):   Verizon   AT&T   Sprint   T-Mobile   Virgin          Verizon     AT&T      Sprint   T-Mobile       Virgin

                   Involvement:                  Edge Core               Transportation                      Hospitality                        Social
                     Circle Any
                                                Fundraising              Service Events                          Adult Advisory Board
                    If you are unable to volunteer your time to support us, please consider making a monetary donation. Thanks!



                   Doctor Name:_______________________________Doctor Phone:______________________
Medical




                   Medical Info / Allergies: ________________________________________________________

                                                                                                                                                 More on
                          If you have any questions, call Pat at 508-0258, or e-mail antiochlifeteen@gmail.com.                                  Reverse

				
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posted:11/8/2011
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