2023-2024 Middle School Ministry Registration "*" indicates required fields Step 1 of 4 25% Please note there is a $50 registration fee (payable securely online or via check). This fee helps to defray the costs of supplies & materials for youth group events. Although registration is required, we would never want costs to deter youth from participating. If you need assistance, please do not hesitate to contact Lynn Pechiney, Program Coordinator. Please fill out all required fields marked with an asterisk (*).Please note there is a $50 registration fee (payable securely online or via check). This fee helps to defray the costs of supplies & materials for youth group events. Although registration is required, we would never want costs to deter youth from participating. If you need assistance, please do not hesitate to contact Lynn Pechiney, Program Coordinator. EARLY BIRD DISCOUNT: Save $10 off your registration if you register before midnight June 30! Your registration is only $40 if you register before that time. Please fill out all required fields marked with an asterisk (*).Student InformationStudent Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone* Student Cell Phone Student Email Address Enter Email Confirm Email Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female 2023-2024 Grade Level*6th7th8thSchool You Attend* Do you have any medical conditions we should know about?Your ParticipationHere are all of the exciting programs you can participant in with All Saints Middle School Ministry: • ASCEND AND MANIA: One night of two exciting programs, filled with games, praise, faith, fun, socializing, food, sports and activities, tasty food, prayer with scripture, making new friends, and bringing along your current friends • MONTHLY OUTINGS: Fun monthly adventures like corn mazes, laser tag, mini-golf, bowling, movies, and more • MIDDLE SCHOOL MISSION: Based on the High School Work Camp, this offers you a chance to make new friends, experience new things, and have lots of fun, while learning about and sharing your faith in the context of community service Plus other fun, faith-filled experiences! Parent/Guardian InformationParent/Guardian Name* First Last Parent/Guardian Email Address* Enter Email Confirm Email Parent/Guardian Cell Phone* Parent/Guardian Work Phone Relationship to teen?* Mother Father Other Additional parent/guardian?* Yes No Additional Parent/Guardian Name First Last Additional Parent/Guardian Email Address Enter Email Confirm Email Additional Parent/Guardian Work Phone Additional Parent/Guardian Cell Phone Relationship to teen? Mother Father Other Parent Volunteer OpportunitiesAre You Virtus-Certified?* Yes No (Virtus is a training program required by, and provided by, the Diocese for all volunteers 18 and over. It is designed to create the safest possible environment for our young people.)In order to make the All Saints Youth Ministry program a success, we need parental help. Please sign up below for areas where you can assist. Just check the boxes.MIDDLE SCHOOL PROGRAMS Shepherd (aka Middle School Mania Chaperone)Help as an extra supervisor during Friday night activities to assist our leaders. RELEASE FORMSCatholic Diocese of Arlington Photo, Press, Audio & Electronic Media ReleaseI authorize the Catholic Diocese of Arlington, its parishes and/or schools to use and publish the photographs and/or motion picture of videotape for which my son/daughter has posed, and/or audio recordings made of her or her voice. I agree that the Catholic Diocese of Arlington, its parishes and/or schools may use such photographs of my son/daughter with or without his or her name and for any lawful purpose, including, for example, such purposes as publicity, illustration, bulletin, and Web content.Parent/Guardian Signature:Please sign in the box above using your mouse (or your finger if you’re on a tablet).Print Your Name: Medical ReleaseI agree to indemnify the All Saints Parish, Youth Ministers, Volunteers, and the Diocese of Arlington for any costs or expenses arising out of my child’s participation in the activities including the cost of any medical care given my child or any expenses or fees incurred in any lawsuit arising as a result of any damage or injuries caused by my child in the course of his or her participation in the activity. I further give my consent to that in my absence the previously-named minor be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the previously-named minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor.Parent/Guardian Signature:*Please sign in the box above using your mouse (or your finger if you’re on a tablet).Print Your Name:* HiddenCOVID-19 Required Agreement for Youth Ministry ParticipantsBecause of our current pandemic, all youth ministry participants are required to have a signed agreement on file. Parents/legal guardians, please read, fill out, and sign the agreement below. Thank you for your understanding!Parish Name: All Saints Catholic ChurchHiddenParish Name HiddenAssumption of RiskThe novel coronavirus and its variants that cause COVID-19 have resulted in a worldwide pandemic and are contagious. In order to continue in-person ministry, the parish named above (“Parish”) has established essential health and safety measures. The Parish has put in place precautionary measures and standards of behavior to reduce the likelihood of spread of COVID-19 in Youth Ministry activities. These measures and standards may be updated during the ministry year. Even with the implementation of these health and safety protocols, however, the Parish and the Catholic Diocese of Arlington cannot guarantee that you or your child(ren) will not become infected with COVID-19. Attendance at the Parish and participation in Youth Ministry activities could increase your risk and/or your child(ren)’s risk of contracting COVID-19. Any interaction with others may result in exposure to, and illness from, communicable diseases including COVID-19. I understand that Youth Ministry activities are not mandatory. By sending my child(ren) for in-person Youth Ministry Activities, I give my informed consent for me or my child(ren) to participate and assume responsibility for the above-noted risks. I willingly agree that my child(ren) and I will comply with the health and safety protocols established by the Parish, including any future modifications to those protocols, and will take all reasonable and necessary additional precautions to protect against communicable diseases while on Parish premises, not only for our own benefit but for the benefit of others with whom we may come into contact. We agree that if we observe any objects, practices or procedures we believe to be hazardous while on Parish premises, we will remove ourselves from the location of such hazards and bring it to the attention of Parish administration immediately.HiddenLiability WaiverBy signing this agreement, I acknowledge the contagious nature of COVID-19 and that my child(ren) and/ or I may be exposed to or infected by COVID-19 by participating in in-person Youth Ministry activities, and that such exposure or infection may result in personal injury, illness, permanent disability, and/or death. I understand that the risk of becoming exposed to or infected by COVID-19 at the above-named Parish may result from the actions, omissions, or negligence of myself, my child(ren) or others, including, but not limited to Diocesan or Parish administrators, employees, volunteers, and other program participants and their families. I further agree on behalf of myself and/or my child(ren) named herein, and our respective heirs, successors, and assigns, fully and forever to release, defend, indemnify, and hold harmless the Catholic Diocese of Arlington, the School, their clergy, administrators, employees, agents, members and volunteers (“Indemnitees”) from any and all claims, damages, demands, and causes of action, present or future, known or unknown, anticipated or unanticipated, in any way related to exposure to COVID-19 while participating in Youth Ministry activities, including but not limited to any claims of negligent exposure. This includes claims that arise from my own and others’ acts, actions, activities and/or omissions, excepting only those that arise solely from the gross negligence, recklessness or intentional torts of Indemnitees, and those that are both (a) not asserted by our child or family or any member thereof, and (b) not alleged to arise from our acts or omissions. With respect to claims alleged to arise from our acts or omissions, our agreement to defend, indemnify and hold harmless the Indemnitees shall be effective only in the event that I, my child, or a member of our family is determined to be liable for such acts or omissions under applicable law, or by agreement. I will defend and indemnify Indemnitees with respect to any released claim, including but not limited to damages, costs and attorney’s fees.HiddenResponsibility for Health ScreeningBy execution of this Statement, I affirm that my or my child(ren)’s presence at named Parish on any day constitutes an affirmative representation on my part that I/we have performed all health screening steps required by the Parish for attendance or participation in Youth Ministry activities. I understand that on any day when my child(ren) does not pass the required health screening (which may include questions relating to other members of the household as well as my child(ren)), I and/or my child(ren) are not permitted to participate in in-person Youth Ministry activities.HiddenNeed to Inform and QuarantineI understand, in the event that I/my child is suspected or confirmed positive with COVID-19 or has come in close contact with a person suspected or confirmed positive with COVID-19, I/my child will need to follow the CDC’s guidance for isolation or quarantine as implemented by the Virginia Department of Health and local health departments. Information is available at www.cdc.gov. I agree to inform the Parish administration as soon as possible, but no later than one (1) business day, after learning of my/my child’s suspected or confirmed positive case of COVID-19 and/or the need to quarantine due to close contact with a person suspected or confirmed positive for COVID-19. I understand that I/my child may not return to in-person Youth Ministry activities until approved by Parish Administration. Approval will be based on confirmation by the local health department that the CDC’s criteria to discontinue home isolation or quarantine has been met.HiddenAuthorization and Informed ConsentI hereby authorize the Parish to enforce such other reasonable measures and directives as may be deemed necessary by the Bishop of the Diocese of Arlington, its Office of Youth, Campus, and Young Adult Ministries, or the Parish leadership. I further understand that, in the event that it becomes necessary that events or programs should be canceled or administered via electronic media, I will not be entitled to a refund of any of my fees. By execution of this Statement, I understand and agree to the foregoing terms and conditions.HiddenParent/Legal Guardian SignatureHiddenType Your Full Legal Name HiddenToday's Date MM slash DD slash YYYY Registration FeeOur online payment system is 100% safe and secure. We do NOT store any of your credit card information. We respect your privacy! You can save time and 100% complete your registration today as it costs you nothing extra to register online!Can you save time and pay the registration fee securely online right now?* Yes, I’ll save myself time and pay safely right now! No, I’ll give you a check. (please choose if you need to defer payment at this time) (Our online payment system is 100% safe and secure. We do NOT store any of your credit card information. We respect your privacy!)Middle School Registration Fee* Price: Billing DetailsCredit Card*Card Details Cardholder Name Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Total: Check PaymentPlease make your check payable to “All Saints Youth Ministry” Drop off in person: All Saints School or Parish Office. Or mail to: All Saints Youth Ministry, 9300 Stonewall Rd, Manassas, VA 20110Total Due: Δ