Catholics In Action

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 Please fill out this field. Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

Birthdate Please enter valid data.

Grade 7 8 9

School REQUIRED Please fill out this field. Please enter valid data.

Gender Male Female

Please list any food allergies and/or medical conditions of which MMR should be aware REQUIRED Please fill out this field.

Parents' names,phone numbers and email addresses REQUIRED Please fill out this field.

Emergency Contact Information REQUIRED Please fill out this field. Please enter valid data.

I Agree to give permission for my child to attend Catholics In Action at MMR Parish. In case of an emergency/ accident I will not hold accountable Gail Polselli (Youth Director), or any of the adult volunteers, staff, clergy, MMR Church, the Office of Youth and Young Adults of the Archdiocese of Philadelphia, or the Archdiocese of Philadelphia as an institution. I give permission for minor first aide to be given if necessary and in an event of an emergency that Gail may procure medical attention.

I Agree Please select this field.

Are you an MMR parishoner yes no

If not, at what parish are you registered Please enter valid data.

Will your teen be attending in order to fulfill a service requirement? yes no

Deadline for registration 9/23/17