St Martin of Tours Parish

Vicksburg, MI
Parish Office: 269-649-1629

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Youth Ministry Registration

- Parish Life

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My child(ren) has my permission to attend Youth Ministry at St. Martin of Tours and will be registering for the 2025 - 2026 Youth Ministry year.

For middle and high school aged child(ren), if applicable, my child(ren) has my permission to attend Youth Ministry events at St. Martin of Tours during the school year calendar of August 2025 - August 2026. The below Medical Release Form and Photo Release Form will cover release for all Youth Ministry events for the 2025-2026 calendar year. I understand that this doesn't cover off-site events sponsored by St. Martin of Tours Youth Ministry and I will still need to complete the necessary forms for these particular events.
Permission to Attend Youth Ministry REQUIRED Yes No Please fill out this field.

Photo Release 2025-2026

I the parent/guardian, grant permission to the staff/volunteers of St. Martin of Tours to reproduce photos taken of my child for the purpose of publication, illustration, promotion, advertising, or any other manner in any medium.

Photo Release Permission REQUIRED I Agree I Do Not Agree Please fill out this field.
Student Name
First Name REQUIRED Please fill out this field. Please enter valid data.

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

Medical Treatment Release 2025-2026

As a parent/guardian, I do hereby authorize the treatment by a qualified and licensed physician of any condition which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me.

Reason for which release is intended: St. Martin of Tours Religious Education/Youth Ministry Events
Child's Age REQUIRED Please fill out this field. Please enter valid data.
Relationship to you REQUIRED Please fill out this field. Please enter valid data.
Minor's Date of Birth: REQUIRED Please fill out this field. Please enter a date.
Grade Entering REQUIRED Please fill out this field. Please enter valid data.
Year of Graduation REQUIRED Please fill out this field. Please enter valid data.
Street 1 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.
Please list ALL persons that are permitted to pick your child up from class: REQUIRED Please fill out this field. Please enter valid data.
Parent Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Phone Type REQUIRED Home Mobile Work Please fill out this field.
Parent Email REQUIRED Please fill out this field. Please enter an email address.
EMERGENCY CONTACT Phone REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Family Physician: Name REQUIRED Please fill out this field. Please enter valid data.
Family Physician: Phone REQUIRED Please fill out this field. Please enter valid data.
Family Physician: Street Address REQUIRED Please fill out this field. Please enter valid data.
Family Physician: City REQUIRED Please fill out this field. Please enter valid data.
List all allergies, medication, contacts, or other pertinent comments REQUIRED Please fill out this field. Please enter valid data.
Health Insurance: Company REQUIRED Please fill out this field. Please enter valid data.
Health Insurance: Policy/Plan/Member Number REQUIRED Please fill out this field. Please enter valid data.
I further authorize the person who presents the minor to sign the Acknowledgement of Receipt of Notice of Privacy Rights that may be presented by the physician or health care facility.

This authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician.
Parent electronic signature

By entering into and/or signing this document, the signatory/signatories agree to conduct its/their dealings via electronic means. The signatory agrees that allowing dealings via electronic means will facilitate these dealings. The signatory has the option to opt to sign things in a paper format.
First Name REQUIRED Please fill out this field. Please enter valid data.

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

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