Martha CYO Registration Form

St. Martha Family Parish
Plainville, MA



Member Information

Name:  ____________________________________________________________________
First Name				Last Name

Address:  _____________________________________________   Town: _________________________

Phone:    ________________________

Sex:   ___	Grade: ______		Date Of Birth:  ____ / _____/_________

Is your child enrolled in St. Martha CCD?	Yes ___   No ___


Parent Information

Father / Guardian Name:  _______________________________________________

Address (if different):  _______________________________________________________________

Telephone (if different): ________________________	Work Phone: ________________________


Mother / Guardian Name:  _______________________________________________

Address (if different):  _______________________________________________________________

Telephone (if different): ________________________	Work Phone: ________________________

Parent Cell Phone Number ______________________


Please check below if you can participate in CYO in any of the areas below:

____	Planning Committee

____	Activity Chaperone

____	Fund-raising

____	Other

____	An activity that you would like to lead or share, such as music, sports and the arts.


Paid   ________			Cash ________		Check # ___________


St. Martha CYO Registration Form						p.2



Other Emergency or Child Pick-up Contacts

List two neighbors or relatives who will assume temporary care of your child if you cannot be reached:

1.	Name:  _______________________________________________

Address:  ___________________________________ Town: _________________________

Phone:    ________________________	Relationship:  ____________________________


2.	Name:  _______________________________________________

Address:  ___________________________________ Town: _________________________

Phone:    ________________________	Relationship:  ____________________________



Medical Information

Does you child have any medical conditions or allergies that CYO should be aware of?     Yes ___ No ___

If yes, describe:  ________________________________________________________________________

______________________________________________________________________________________


In case of accident or serious illness, I request that CYO contact me.  If CYO is unable to reach me, I hereby authorize CYO to call the physician indicated below and follow his/her instructions.  If it is impossible to contact this physician, CYO may make whatever arrangements seem necessary.

Doctor:   ______________________________________________________________

Address:  ___________________________________ 	Town:  _________________________

Phone:    ________________________


Waiver Form

In consideration for my child’s entry into St. Martha CYO, I hereby, for myself, my heirs, my executors and administrators waive and release all claims for damages against St. Martha CYO, St. Martha Family Parish and its members for any and all injuries and illnesses which directly or indirectly result from my child’s participation in CYO events, except where negligence is involved.


Signature of Parent or Guardian  ______________________________	Date___________________