Thank you for your interest in the Alpha for Teens series.  We ask that parents complete this form for their youth.  We welcome all youth to participate in these sessions, and ask that youth who are attending more than one session register.  If you have any questions or concerns, please contact Fr. Kyle Kilpatrick in the parish office (kkilpatrick@stfrancisholland.org).

Student
Family Information
Emergency Contact | Contacto en caso de emergencia
Media Relations/Promotions Release | Relaciones con los medios de comunicación/promociones de comunicado
IF PERSON BEING USED IN THE MATERIAL IS UNDER 18 YEARS OF AGE, PARENT OR LEGAL GUARDIAN MUST SIGN THIS FORM. SI LA PERSONA REQUERIDA PARA EL MATERIAL ES MENOR DE 18 AÑOS DE EDAD, EL PADRE/MADRE O TUTOR LEGAL DEBERA FIRMAR ESTA FORMA I/we give my/our permission to St. Francis de Sales, Our Lady of the Lake, the Roman Catholic Diocese of Grand Rapids, Michigan, (the Diocese) and all entities, representatives, employees, and agents operating under its authority to use, without prior notice, my name or my minor child’s name, city and state, and/or audio, video(s), photo(s), and/or any other likeness and to use statements made by or attributed to me or my child relating to the Diocese, without compensation, for web, social media, publicity or similar promotions for the Diocese. I waive my right to inspect or approve such publications, including any written copy that may be created in connection therewith. I/we agree that my/our signature(s) below releases any and all claims against the Roman Catholic Diocese of Grand Rapids, or its associated entities related to or arising out of the Diocese’s use of the stated items as media relations/promotional material(s).
Authorization for Electronic Interaction with Minor
With the continuing evolution of new media and next generation communications tools, the way in which our parish, school, and families can communicate internally and externally continues to develop at a rapid pace. Electronic communication by personnel of our parish and school with your children is not taken lightly. Our parish employees and volunteers consistently adhere to Catholic values and transparency with respect to such communications. As the parent/guardian, I understand that I will receive communication regarding my child’s participation in programs and activities. I grant permission to the parish, its staff and authorized volunteers to communicate with my child, for the purpose of relaying program and event invitations, course-related academics and activities through electronic mediums. Con la continua evolución de los nuevos medios y las herramientas de comunicación de próxima generación, la forma en que nuestra parroquia, la escuela y las familias se pueden comunicar interna y externamente continúa desarrollándose a un ritmo rápido. La comunicación electrónica del personal de nuestra parroquia y escuela con sus hijos no se toma a la ligera. Usted puede tener la expectativa de que los empleados y voluntarios de nuestra parroquia se apeguen consistentemente a los valores católicos y la transparencia con respecto a tales comunicaciones. (Para obtener más información, consulte la Política de medios sociales de la Diócesis de Grand Rapids, Sección V "Interacción de adultos con menores"). Como padre / tutor, entiendo que recibiré comunicación con respecto a la participación de mi hijo en programas y actividades.
Medical Treatment Release | Potestad a Tratamiento Médico
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. I further authorize the person who presents the minor to sign the Acknowledgement of Receipt of Notice 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. Como pariente / guardián, yo autorizo el tratamiento de primeros auxilios /médico para mi hijo(a) en el caso eventual de una emergencia que pone en peligro su vida, causaría desfiguración, discapacidad física, o incomodidad excesiva si no es atendido oportunamente. Se entiende que harán esfuerzos para contactarme en cuanto sea razonablemente posible. Este formulario de consentimiento es completado y firmado de mi propia libre voluntad con el único propósito de autorizar tratamiento médico bajo circunstancias de emergencia en mi ausencia. Esta autorización se completa y firmado por mi propia voluntad con la finalidad de autorizar tratamiento médico, que se considera necesario y apropiado por el médico tratante.