Flocknote Phone Instagram YouTube Facebook

DISCOVERY 2025
May 3-4

- 2024 Youth Witness Talks
- ST. JOSEPH YOUTH MINISTRY
  DISCOVERY 2025
  ONLINE PERMISSION & PAYMENT FORM
  COMPLETE THIS FOR
  LEADERS
  and/or
  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 DISCOVERY Retreat to be held May 3-4, 2025 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.
  
  DISCOVERY Registration Cost45.0
  
  Total:
  
  Submit
  
  Proceed to Payment
  
  This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
- Questions
  
  Joseph LeMay
  
  Interim Director of Youth Ministry
  
  630-964-0216 x1210
  jlemaysjpdg.org
  
  Cindy Jagielo
  
  Acting Dir. of Confirmation, RE & YM Program Asst
  
  630-964-0216 x1208
  cjagielosjpdg.org

DISCOVERY 2025May 3-4

ST. JOSEPH YOUTH MINISTRY DISCOVERY 2025ONLINE PERMISSION & PAYMENT FORM

LEADERSand/orPARTICIPANTS

DISCOVERY 2025
May 3-4

ST. JOSEPH YOUTH MINISTRY
DISCOVERY 2025
ONLINE PERMISSION & PAYMENT FORM

LEADERS
and/or
PARTICIPANTS