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FLAME

- Youth Witness Talks
- ST. JOSEPH YOUTH MINISTRY
  FLAME 2024
  ONLINE PERMISSION & PAYMENT FORM
  
  COMPLETE THIS FOR
  
  FLAME "LEADERS"
  and/or
  FLAME "PARTICIPANTS"
- Register Online
  
  The maximum number of form submissions has been reached. This form is currently not available.
  
  Parent/Guardian Contact Information
  
  Parent/Guardian #1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Address 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.
  
  Cell REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Parent/Guardian #2
  
  First Name Please enter valid data.
  
  Last Name Please enter valid data.
  
  Address (if different from above) Please enter valid data.
  
  City Please enter valid data.
  
  State
  
  Zip Please enter a zip code.
  
  Cell Maximum 20 characters Please enter a phone number.
  
  Email Please enter an email address.
  
  Teens Attending REQUIRED Please fill out this field.
  
  Teen 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Choose One REQUIRED Participant Leader Please fill out this field.
  
  Teen Cell REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Birthdate REQUIRED Please fill out this field. Please enter a date.
  
  Grade in Fall REQUIRED Please fill out this field. Please enter valid data.
  
  Allergies / Health Information
  
  Teen 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Choose One REQUIRED Participant Leader Please fill out this field.
  
  Teen Cell REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Birthdate REQUIRED Please fill out this field. Please enter a date.
  
  Grade in Fall REQUIRED Please fill out this field. Please enter valid data.
  
  Allergies / Health Information
  
  Teen 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Choose One REQUIRED Participant Leader Please fill out this field.
  
  Teen Cell REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Birthdate REQUIRED Please fill out this field. Please enter a date.
  
  Grade in Fall REQUIRED Please fill out this field. Please enter valid data.
  
  Allergies / Health Information
  
  Teen 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Choose One REQUIRED Participant Leader Please fill out this field.
  
  Teen Cell REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Birthdate REQUIRED Please fill out this field. Please enter a date.
  
  Grade in Fall REQUIRED Please fill out this field. Please enter valid data.
  
  Allergies / Health Information
  
  Emergency Contacts
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  First Name Please enter valid data.
  
  Last Name Please enter valid data.
  
  Phone Number Maximum 20 characters Please enter a phone number.
  
  Parent Consent Form
  
  I/We the parent(s) of
  
  Participants Name(s) REQUIRED Please fill out this field. Please enter valid data.
  
  request that the parish allows my child to participate in the FLAME Retreat to be held June 22-23, 2024 at St. Joseph Parish. In consideration for making the arrangements for this activity, we hereby release and save harmless the parish, archdiocese, its employees, officers and agents from any and all liability, suits, causes and claims arising to my/our son/daughter as a result of, or in connection with, this activity. In case of injury or related Emergency, I/we authorize that First Aid be administered to my/our child by a person qualified to render such service if deemed necessary by the Director of Youth Ministry or chaperones. Please note allergies, special needs/health conditions and any medication youth is taking.
  
  I have read and understand the above statement.
  I Agree Please select this field.
  
  Health Insurance Information
  
  Name of Insurance Company REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Policy Number Please enter valid data.
  
  ID Number Please enter valid data.
  
  FLAME Registration Cost30.0
  
  Total:
  
  Submit
  
  Proceed to Payment
  
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- Questions
  
  Cindy Jagielo
  
  Acting Dir. of Confirmation, RE & YM Program Asst
  
  630-964-0216 x1208
  cjagielosjpdg.org
  
  Clare Johnson
  
  Interim Youth Minister
  
  630-964-0216 x1206
  cjohnsonsjpdg.org

FLAME

Youth Witness Talks

ST. JOSEPH YOUTH MINISTRY
FLAME 2024
ONLINE PERMISSION & PAYMENT FORM

FLAME "LEADERS"
and/or
FLAME "PARTICIPANTS"

Register Online

Questions

FLAME

ST. JOSEPH YOUTH MINISTRY FLAME 2024 ONLINE PERMISSION & PAYMENT FORM

FLAME "LEADERS" and/orFLAME "PARTICIPANTS"

ST. JOSEPH YOUTH MINISTRY
FLAME 2024
ONLINE PERMISSION & PAYMENT FORM

FLAME "LEADERS"
and/or
FLAME "PARTICIPANTS"