Please print

Name:______________________________Phone: ( )________________________

Address:_____________________________e-mail address:_______________________

City:_______________________________Date of Birth:_________________________

State:______________________Zip:____________________

Religion:___________________________Church:___________________________

School Attending:_______________________________Grade:___________

Parent or Guardian:______________________________________________________

Emergency Phone Number:_________________________________________________

Emergency Contact:_______________________Phone Number: ( )___________

I (we) the parent or guardian of the above named child, hereby give consent for my child to participate in any and all of the activities of the St.Catherine’s CYO, Middletown, New Jersey, during the 2002-2003 year. I (we) assume all risks and hazards incidental to the conduct of these activities and release, absolve, and hold harmless the St.Catherine’s CYO, St.Catherine’s Church, Middletown, New Jersey, and any or all of its directors and coaches.

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Parent of Guardian (please print) Member (please print)

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Parent or Guardian (please sign) Member (please sign)