65th Archdiocesan Youth Conference Registration Forms - Archdiocese of ...
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Registration Forms
AYC Packet #2
65th Archdiocesan Youth Conference
Registration Forms
June 8, Revised Edition, p.1
Accounting Sheet - Regular Registration
2021 Archdiocesan Youth Conference
Regular Registration closes on July 1, 2021
(payment Must be Hand Delivered or postmarked No later Than June 23, 2017)
ALL payments due in the office by July 20, 2021
Please make copies of this form as needed.
We ask for a new form to be completed each time additions are made to your parish/school delegation. Thank you!
Parish/School: Group Leader:
(Attending the Conference)
Work Phone #: Cell Phone #:
Address: City: ___________________ Zip code:
Email Address:
Registration Fees: Start with Line 1. Do not skip any lines.
1. Total number of Youth Participants (high school youth including 2021 Graduates) X $155= $
2. Total number of Adults - 21 yrs and older (Group Leaders & Chaperones) X $155= $
3. Add Lines 1 through 2 for Registration Subtotal= $
Additional Fees: provide subtotals for all that apply
4. T-shirt Orders: _____Small x $12.00= $
5. _____Medium x $12.00= $
6. _____Large x $12.00= $_____________
7. _____XL x $14.00= $_____________
8. _____XXL x $14.00= $_____________
9. _____XXXL x $15.00= $_____________
10. _____XXXXL x $15.00= $
(Note: T-shirt order will be based on this accounting sheet numbers and not on the Cvent)
11. Add Lines 4 through 10 for T-Shirt Subtotal= $
12. Add Lines 3 and 11- for Sub-Total Amount Owed: $_____________
13. Amount received in Scholarship -$
(Use this line If Scholarship was Requested and Approved by OACE Director)
14. Subtract line 13 from line 12 for Total Amount Owed: $_____________
Please make checks payable to the Office of Adolescent Catechesis and Evangelization.
Very few (if any) AYC t-shirts will be available onsite.
June 8, Revised Edition, p.2Accounting Sheet - LATE Registration
2021 Archdiocesan Youth Conference
Late Registration closes on July 9, 2021
(payment Must be Hand Delivered or postmarked No later Than June 23, 2017)
Payment due in the office by July 20, 2021
Please make copies of this form as needed.
We ask for a new form to be completed each time additions are made to your parish/school delegation. Thank you!
Parish/School: Group Leader:
(Attending the Conference)
Work Phone #: Cell Phone #:
Address: City: ___________________ Zip code:
Email Address:
Registration Fees: Start with Line 1. Do not skip any lines.
1. Total number of Youth Participants (high school youth including 2021 Graduates) X $165= $
2. Total number of Adults - 21 yrs and older (Group Leaders & Chaperones) X $165= $
3. Add Lines 1 through 2 for Registration Subtotal= $
Additional Fees: provide subtotals for all that apply
4. T-shirt Orders: _____Small x $12.00= $
5. _____Medium x $12.00= $
6. _____Large x $12.00= $_____________
7. _____XL x $14.00= $_____________
8. _____XXL x $14.00= $_____________
9. _____XXXL x $15.00= $_____________
10. _____XXXXL x $15.00= $
(Note: T-shirt order will be based on this accounting sheet numbers and not on the Cvent)
11. Add Lines 4 through 10 for T-Shirt Subtotal= $
12. Add Lines 3 and 11- for Sub-Total Amount Owed: $_____________
13. Amount received in Scholarship -$
(Use this line If Scholarship was Requested and Approved by OACE Director)
14. Subtract line 13 from line 12 for Total Amount Owed: $_____________
Please make checks payable to the Office of Adolescent Catechesis and Evangelization.
Very few (if any) AYC t-shirts will be available onsite.
June 8, Revised Edition, p.3AYC Scholarship Application Form – Electronically Submitted or
Hand Delivered by June 21, 2021
Application Process
A scholarship application can only be made by the youth participant once per program year (July 1-June 30).
The maximum scholarship awarded is $100 and will only go toward the registration cost. This does not include housing,
travel, or meals not provided by AYC. Full scholarship awards are not guaranteed.
Scholarships will be distributed based on an individual need and not on a parish/school need.
Participants who have been awarded scholarships and failed to participate or attend the program, forfeit the opportunity to
apply for scholarship during the remaining program year and the scholarship is non-transferrable.
Scholarship forms, essays and registration forms must be completed and returned to the Office of Adolescent Catechesis
and Evangelization by the program scholarship deadline. All applicants’ forms must be submitted as one packet by the
catechetical leader/campus ministry leader with a cover letter verifying the financial need.
Scholarship awards are non-transferable. Late fees or substitution fees are not included in scholarship awards.
We will not provide scholarship for the entire school/parish delegation. Participants must apply individually.
In a one page essay, the teen is to share how AYC will be of benefit to his/her faith life through attendance and active
participation in the conference. Please attach to this form. It must be an original essay not a generic one used by several
youth. If the essay is not included, the scholarship request will be denied.
To Be Completed by the Parish Catechetical Leader or High School Campus Ministry Leader
How much is the full registration fee for the parish/school including hotel? $
Please share details of costs beyond registration and hotel
Meals not provided by AYC (Per Person) $
Transportation (Per Person) $
Parish/School T-Shirts (Per Person) $
Other Costs: (Per Person) $
How much is the parish/school contributing through budget and/or fundraising? $
(Each parish/school is expected to contribute something toward the cost of the event.)
Parish/School Catechetical Leader Signature (DYM/DRE/Campus Minister) Date
Pastor/School Principal Signature Date
To Be Completed by the Parent - Generic figures filled in by parish/school personnel will not be considered.
Of the $155 registration fee, how much are you able to contribute? $
(Each participant is expected to contribute something toward the cost of the event.)
How much financial assistance is being requested from the Archdiocese? $
(The request cannot be for more than $100)
Youth Participant Signature Date
Parent/Guardian Signature Date
June 8, Revised Edition, p.42021 Archdiocesan Catholic Youth Conference
Substitution Form
Parish:
Group Leader: Daytime Phone:
Cell Phone:
Address:
City: Zip:
DELETE the following:
Name:
________________________________________________ _____ Youth _____ Adult
________________________________________________ _____ Youth _____ Adult
________________________________________________ _____ Youth _____ Adult
REPLACE with the following:
Name:
_______________________________________ _____ Youth _____ Adult ____ Vaccine or Test Verification
_______ Forms Provided
_______________________________________ _____ Youth _____ Adult ____ Vaccine or Test Verification
_______ Forms Provided
_______________________________________ _____ Youth _____ Adult ____ Vaccine or Test Verification
_______ Forms Provided
A $20.00 charge will be made for each substitution ________ X $20.00 Total ___________
Amount Enclosed _____________
PAYMENT MUST ACCOMPANY THIS FORM
June 8, Revised Edition, p.5TO BE USED FOR SUBSTITUTIONS AFTER ONLINE REGISTRATION CLOSES
Archdiocese of Galveston-Houston Office of Adolescent Catechesis and Evangelization
PARENTAL/GUARDIAN CONSENT FORM & LIABILITY WAIVER
Participant’s Name Date of Birth
Home Address City/Zip Code
Parent(s)/Guardian(s) Home Phone (___)
Parent Alternate Phone Number: (___) _____________ (Cell Phone or Work)
Parish or Catholic School Grade _____ Age_____ Sex____
Participant’s Email Address
Parent Email Address: _________________________________________________________________________________
CONSENT & LIABILITY WAIVER
Important! To be filled out by the Parent/Guardian for youth under 18 years of age.
(If participant is 18 years of age or older, consent must be signed by the individual)
I (name of parent/guardian) ___________________________________, grant permission for my child, (participant’s name),
_________________________________ to participate in the Archdiocesan Youth Conference to be held July 30-August 1, 2021
at Hilton Americas Hotel and Discovery Green, in downtown Houston.
In consideration of my child’s participation in this event, I agree on behalf of myself, my child named herein, and our heirs,
successors, and assigns to indemnify, hold harmless and defend the Archdiocese of Galveston-Houston, the sponsoring parish, its
pastor, youth ministry leader, principal, other agents, employees or other representatives associated with the event from any and all
injuries, losses or claims arising out of my child’s participation in the event.
In signing this form I certify that all information contained herein is true and accurate to the best of my knowledge.
___________________________________________________________ ______________________
Signature (Parent/Guardian) Date
YOUTH PARTICIPANT: In signing the line below I agree to abide by any/all policies and rules established for this event/activity
(see Code of Conduct). Should I not be able to maintain the guidelines and expectations of the adults and my peers, I understand that
there will be consequences for my actions, including being removed from the activity and being sent home at my parent’s expense.
_________________________________________________________ _____________________
Signature (Youth Participant) Date
VIDEO/PHOTOGRAPHY CONSENT
As parent/guardian, I understand that promotional pictures and videos (individual and group) will be taken during this event. I give
permission for my son’s/daughter’s picture to be used for promotional materials (newsletter, web page, calendars, power point, video
etc.) in highlighting the event.
______________________
Signature (Parent/Guardian) Date
June 8, Revised Edition, p.6TO BE USED FOR SUBSTITUTIONS AFTER ONLINE REGISTRATION CLOSES
ARCHDIOCESE OF GALVESTON-HOUSTON MEDICAL CONSENT FORM
Medical Matters
I hereby warrant to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.
Of the following statements pertaining to medical matters, sign only those in accordance with your wishes:
Emergency Medical Treatment
In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical
treatment. I wish to be advised prior to any further treatment by the hospital or doctor.
In the event of an emergency and you are unable to reach me, contact:
Name & Relationship _________________________________ Phone ___________________________
Family Doctor ______________________________________ Phone___________________________
Medications
My child will bring all such medications, well labeled, that are necessary. Names of medications and concise directions for seeing
that the child takes such medications, including dosage and frequency are as follows
My child is taking the following medication at the present time.
Medication(s): ________________________________________________ Dosage: _____________________
Administer: _______________________________________________________________________________
_____ I hereby Do Not Grant Permission for medication of any type, whether prescription or nonprescription, to be administered
by my child unless the situation is life threatening and emergency treatment is required. (Please initial)
OR
_____I hereby Grant Permission for nonprescription medication (such as Tylenol, throat lozenges, cough syrup) to be given to my
child, if deemed advisable. I understand that Aspirin will not be given to my son/daughter. (Please initial)
Medical Conditions Information: (Archdiocesan personnel will take reasonable care to see that the following information will be held in confidence.)
My son/daughter has:
Has had an episode the following or has been diagnosed: ____ Seizures ____ Asthma _____ Diabetic
Allergic reactions to the following (foods, dyes, latex etc.)
Has had a medical surgery within the last six months? ___ Yes___ No Still under doctor’s care? ___ Yes ___ No
Has a medically prescribed diet?
The following physical limitations?
Immunizations current and up to date: ____ Yes ____ No Date of last tetanus/diphtheria immunization
You should also be aware of these special medical conditions of my child (e.g. depression, anxiety, etc.):
Insurance Information:
____ No, I do not carry medical insurance at this time.
Insurance Carrier: Name of Insured:
Insurance Policy Number:
Father’s Name: Day Phone:
Mother’s Name: Day Phone:
In the event it comes to the attention of the chaperones associated with the activity that my child becomes ill with repeated symptoms
such as headache, vomiting, sore throat, fever, diarrhea, I want to be called immediately. If this will be a long distance call, I want to
be called collect (with phone charges reversed to myself). I fully understand the foregoing statements and sign this Parental/Guardian
Medical Consent Waiver knowingly, freely, and willingly.
Signature (Parent/Guardian) Parent/Guardian Date
June 8, Revised Edition, p.7ARCHDIOCESAN YOUTH CONFERENCE
July 30, 2021- August 1, 2021
COVID-19
ADULT CONSENT AND LIABILITY WAIVER
The virus that causes COVID-19 can infect people of all ages. Persons of ALL AGES can be
infected with COVID-19 and some will develop a severe illness.
Anyone with a mild or asymptomatic case of COVID-19 can spread the infection to others,
including those who may be far more vulnerable.
Precautions will be taken at the Archdiocesan Youth Conference (AYC), however, some of the
protective measures that we can expect are, for a variety of reasons, simply not practicable for
some, particularly children.
COVID-19 is easily spread from person to person by coughing, sneezing, speaking, and even
breathing. A group of people may not maintain social distancing and other safeguards.
Adults should monitor their health and NOT attend the AYC if they are displaying any symptom
of COVID-19.
Name: _____________________________________________________________________________
Home Address: ______________________________________________________________________
Home Phone: _________________ Business Phone: ________________ Cell Phone: ______________
Sponsoring Parish/School: ______________________________________________________________
I acknowledge that I am aware of the COVID-19 virus and I acknowledge that I may be exposed to the
virus while attending the AYC. I agree I will not attend the AYC if I display any symptoms of COVID-19
or have been exposed to anyone with COVID-19. I will notify the OACE staff immediately if I am exposed
or develop symptoms. I agree to comply with rules and directives of the AYC. I understand that the AYC
will include group activities, overnight stays and meals served in a group setting.
IN CONSIDERATION OF BEING ABLE TO ATTEND AYC I AGREE ON BEHALF OF MYSELF,
OR MY HEIRS, SUCCESSORS, AND ASSIGNS, TO HOLD HARMLESS, RELEASE AND
DEFEND THE ARCHDIOCESE OF GALVESTON-HOUSTON, THE SPONSORING
PARISH/SCHOOL, AND THEIR EMPLOYEES, OFFICERS, VOLUNTEERS, AGENTS, OR
REPRESENTATIVES FROM ANY CLAIMS, DAMAGES OR LIABILITIES ARISING FROM
COVID-19 IN CONNECTION WITH MY ATTENDANCE AT THE AYC, INCLUDING ANY COVID-
19-RELATED ILLNESS OR INJURY OR COSTS OF MEDICAL TREATMENT FOR COVID-19.
Signature: __________________________________________ Date: ___________________________
June 8, Revised Edition, p.8ARCHDIOCESAN YOUTH CONFERENCE
July 30, 2021- August 1, 2021
COVID-19
PARENT/GUARDIAN CONSENT AND LIABILITY WAIVER
The virus that causes COVID-19 can infect people of all ages. Persons of ALL AGES can be
infected with COVID-19 and some will develop a severe illness.
Even a child with a mild or asymptomatic case of COVID-19 can spread the infection to others,
including those who may be far more vulnerable.
While precautions will be taken at the Archdiocesan Youth Conference (AYC), some of the
protective measures that we can expect from adults are, for a variety of reasons, simply not
practicable for children.
COVID-19 is easily spread from person to person by coughing, sneezing, speaking, and even
breathing. A group of young people may not maintain social distancing and other safeguards.
Parents and Guardians should monitor the health of their child and NOT send their child to the
AYC if the child is displaying any symptom of COVID-19.
Child’s name: ___________________________________ Child’s Date of Birth: __________________
Father/Guardian’s name print):__________________________________________________________
Home Address: ______________________________________________________________________
Home Phone: __________________ Business Phone: ________________ Cell Phone: _____________
Sponsoring Parish/School: _____________________________________________________________
I, _____________________________________, grant permission for my child,
_____________________________________, to participate in the AYC. This will take place
under the guidance and direction of the Office of Adolescent Catechesis and Evangelization
(OACE) of the Archdiocese of Galveston-Houston (ARCHGH) and the staff and volunteers of the
AYC.
As parent and/or legal guardian of the child I acknowledge that I am aware of the COVID-19 virus and I
acknowledge that my child may be exposed to the virus while attending the AYC. I agree I will not allow
my child to attend the AYC if my child displays any symptoms of COVID-19 or has been exposed to
anyone with COVID-19. I will notify my parish/school group leader, the OACE staff or AYC volunteer
immediately if my child is exposed or develops symptoms. I agree to comply with rules and directives of
the AYC. I understand that the AYC will include group activities, overnight stays and meals served in a
group setting.
IN CONSIDERATION OF MY CHILD BEING ABLE TO ATTEND AYC I AGREE ON BEHALF OF
MYSELF, MY CHILD NAMED HEREIN, OR OUR HEIRS, SUCCESSORS, AND ASSIGNS, TO HOLD
HARMLESS, RELEASE AND DEFEND THE ARCHDIOCESE OF GALVESTON-HOUSTON, THE
SPONSORING PARISH/SCHOOL, AND THEIR EMPLOYEES, OFFICERS, VOLUNTEERS, AGENTS,
OR REPRESENTATIVES FROM ANY CLAIMS, DAMAGES OR LIABILITIES ARISING FROM COVID-
19 IN CONNECTION WITH MY CHILD’S ATTENDANCE AT THE AYC, INCLUDING ANY COVID-19-
RELATED ILLNESS OR INJURY OR COSTS OF MEDICAL TREATMENT FOR COVID-19.
Signature: _______________________________________ Date: __________________________
June 8, Revised Edition, p.9ARCHDIOCESAN YOUTH CONFERENCE
July 30, 2021- August 1, 2021
COVID-19
PARENT/GUARDIAN CONSENT AND LIABILITY WAIVER
The virus that causes COVID-19 can infect people of all ages. Persons of ALL AGES can be
infected with COVID-19 and some will develop a severe illness.
Even a child with a mild or asymptomatic case of COVID-19 can spread the infection to others,
including those who may be far more vulnerable.
While precautions will be taken at the Archdiocesan Youth Conference (AYC), some of the
protective measures that we can expect from adults are, for a variety of reasons, simply not
practicable for children.
COVID-19 is easily spread from person to person by coughing, sneezing, speaking, and even
breathing. A group of young people may not maintain social distancing and other safeguards.
Parents and Guardians should monitor the health of their child and NOT send their child to the
AYC if the child is displaying any symptom of COVID-19.
Child’s name: __________________________________ Child’s Date of Birth: ___________________
Mother/Guardian’s name (print):_________________________________________________________
Home Address: _______________________________________________________________________
Home Phone: _________________ Business Phone: _______________ Cell Phone: _______________
Sponsoring Parish/School: ____________________________________________________________
I, __________________________________________, grant permission for my child,
______________________________________, to participate in the AYC. This will take place
under the guidance and direction of the Office of Adolescent Catechesis and Evangelization
(OACE) of the Archdiocese of Galveston-Houston (ARCHGH) and the staff and volunteers of the
AYC.
As parent and/or legal guardian of the child I acknowledge that I am aware of the COVID-19 virus and I
acknowledge that my child may be exposed to the virus while attending the AYC. I agree I will not allow
my child to attend the AYC if my child displays any symptoms of COVID-19 or has been exposed to
anyone with COVID-19. I will notify my parish/school group leader, the OACE staff or AYC volunteer
immediately if my child is exposed or develops symptoms. I agree to comply with rules and directives of
the AYC. I understand that the AYC will include group activities, overnight stays and meals served in a
group setting.
IN CONSIDERATION OF MY CHILD BEING ABLE TO ATTEND AYC I AGREE ON BEHALF
OF MYSELF, MY CHILD NAMED HEREIN, OR OUR HEIRS, SUCCESSORS, AND ASSIGNS,
TO HOLD HARMLESS, RELEASE AND DEFEND THE ARCHDIOCESE OF GALVESTON-
HOUSTON, THE SPONSORING PARISH/SCHOOL, AND THEIR EMPLOYEES, OFFICERS,
VOLUNTEERS, AGENTS, OR REPRESENTATIVES FROM ANY CLAIMS, DAMAGES OR
LIABILITIES ARISING FROM COVID-19 IN CONNECTION WITH MY CHILD’S ATTENDANCE
AT THE AYC, INCLUDING ANY COVID-19-RELATED ILLNESS OR INJURY OR COSTS OF
MEDICAL TREATMENT FOR COVID-19.
Signature: ___________________________________ Date: _______________________________
June 8, Revised Edition, p.10Archdiocese of Galveston-Houston
Key Leader, Chaperone and Young Adult Assistant
Medical Release and Liability Form
I, , do hereby release, hold harmless and discharge the
Archdiocese of Galveston-Houston, the parish, its staff and volunteers from any and all liability, claim, loss,
damage, cost or expense arising from my participation in this event. I waive such claims against such
organization or any such person, arising directly or indirectly from or attributable in any legal way, to any action
or omission to act of any such organization or person in connection with execution of this event. I authorize
treatment by a licensed medical physician or licensed medical team in case of any accident or illness that may so
arise, or any hospitalization necessary.
Print Name Date:
Address
City Zip
Parish
Home Phone ( ) Work Phone ( )
Physician's Name Phone ( )
(The following request is pertinent information if you rendered unconscious)
Date of Birth (including year): Age:
Date of last Tetanus shot:
Please list ALL medical conditions / allergies / special health information including bouts with depression and
anxiety:
Please list ANY medications (prescription or non-prescription) you would like us to be aware of:
Do you have Medical Insurance: □ Yes □ No
If Yes, Please provide the following information:
Insurance Company: _________________________________________________________________
Policy in the name of: Policy Number: ___________________
Name of Emergency Contact: Phone Number: (____) _________________
In the event the participant does not have insurance, payment in full for medical care becomes the
responsibility of the patient.
Signature__________________________________________________________
In signing the line above I agree to abide by any/all policies and rules established for this event/activity (see Code of
Conduct). Should I not be able to maintain the guidelines and expectations of the adult chaperones, I understand that
there will be consequences for my actions, which could include being asked to leave the event.
June 8, Revised Edition, p.11Notes
June 8, Revised Edition, p.12You can also read
