Youth Membership Application

Youth Application
- The maximum number of form submissions has been reached. This form is currently not available.
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Guardian's Name REQUIRED Please fill out this field. Please enter valid data.
  
  Sex REQUIRED Please fill out this field.
  
  Age REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth 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.
  
  Address 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.
  
  School REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter valid data.
  
  Teacher REQUIRED Please fill out this field. Please enter valid data.
  
  Who does youth live with? REQUIRED Please fill out this field.
  
  Emergency Contact 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.
  
  Medical Information
  
  Waiver of Responsibility
  
  By checking I agree, I give my permission for my child to:
  Participate in all activities held at, or sponsored by, Ryves Youth Center at Etling Hall, Catholic Charities Terre Haute, the archdioceses of Indianapolis, or any agent thereof. I also give my permission for my child to participate in any field trip, or outing, sponsored by Ryves Youth Center at Etling Hall, Catholic Charities Terre Haute, or their agents thereof. I also give my permission for my child to be used in any promotional material (videotaped, photographed, or audio taped) by Ryves Youth Center at Etling Hall, Catholic Charities Terre Haute, the news media, or any of the above-designated agent(s). I realize that the above-mentioned media may be used for publicity or educational purposes. I also give my permission for my child to be interviewed, photographed, video or audio taped, by the news media. I also give my permission for my child to participate in support groups and counseling sessions provided by Ryves Youth Center at Etling Hall, Catholic Charities Terre Haute, or any agent thereof. I also give permission for my child to participate in any written or verbal surveys conducted by Ryves Youth Center at Etling Hall, Catholic Charities Terre Haute, or any designated agent or collaborator. I realize that activities at Ryves Youth Center at Etling Hall are educational, recreational, and supportive in nature. I also realize that outside organizations provide activities and field trips for members of Ryves Youth Center at Etling Hall. I give my permission for my child to participate in these activities and field trips. I will not hold Ryves Youth Center at Etling Hall, Catholic Charities Terre Haute, or any agent thereof responsible for any accident happening to my child. I also give my permission for my child to receive emergency first aid and medical treatment in case of accident or illness.
  I Agree Please select this field.
  
  If you have any questions or problems feel free to call us at (812) 235-1265, or stop by at 1356 Locust Street. Our hours are 8:00 am-5:00pm (Preschool) and 1:00pm-9:00pm (Youth Center).
  
  Submit
  
  This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.