BCYC June 19-23, 2025 Registration

- The maximum number of form submissions has been reached. This form is currently not available.
  
  Teen (Minor) Participant
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth (DD/MM/YYYY) REQUIRED
  DD/MM/YYYY
  Please fill out this field. Please enter a date.
  
  Teen Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Age at the time of BCYC REQUIRED Please fill out this field.
  
  Gender REQUIRED Male Female Please fill out this field.
  
  T-Shirt Size REQUIRED Please fill out this field.
  
  PRIMARY- Parent/Guardian
  
  Relationship to Minor REQUIRED Please fill out this field. Please enter valid data.
  
  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.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Mailing 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.
  
  SECONDARY- Parent/Guardian
  
  Relationship to Minor Please enter valid data.
  
  First Name Please enter valid data.
  
  Last Name Please enter valid data.
  
  Phone Number Maximum 20 characters Please enter a phone number.
  
  Email Please enter an email address.
  
  Mailing Address Please enter valid data.
  
  City Please enter valid data.
  
  State
  
  Zip Please enter a zip code.
  
  Medical/Insurance Information
  
  The following is medical information for minor participant, REQUIRED Please fill out this field. Please enter valid data.
  
  With exception of restrictions called out below I/We hereby assume all health of my/our child and warrant that to the best of my/our knowledge they are in good health and that medical insurance information is accurate. I/We understand that in the event medical treatment is required, every effort will be made to contact me. However, if I/We cannot be reached, I/We give permission to the staff or sponsor to secure the services of a licensed physician or other healthcare provider to administer the necessary care, including anesthesia, for my child’s wellbeing. (Enter "none" or "N/A" for each, if teen has none of the following.)
  
  Medical Conditions REQUIRED Please fill out this field. Please enter valid data.
  
  Food Allergies REQUIRED Please fill out this field. Please enter valid data.
  
  Disabilities, Physical or Developmental Limitations REQUIRED Please fill out this field. Please enter valid data.
  
  Health Insurance Company: REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number for Insurance Company REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Insurance Identification Number: REQUIRED Please fill out this field. Please enter valid data.
  
  Insurance Group # REQUIRED Please fill out this field. Please enter valid data.
  
  eSignature PRIMARY Parent/Guardian REQUIRED This box acts as my eSignature Please fill out this field.
  
  Offsite Activity Release for Minor Participant
  
  We hereby release the Diocese of Pueblo, its staff, and the adult volunteers, of the responsibility of possible injury, accident, sickness, etc. that might occur when participating in the High School Youth Group. I/We understand that those involved are taking all reasonable precautions to create a safe environment.
  
  I/We release the Diocese of Pueblo and its agents and employees from all claims, demands, or liabilities in connection with events my daughter/son participate in. As parent and/or legal guardian, I/We remain legally responsible for any personal actions taken by the above-named minor participant. I/We agree on behalf of myself, child named as minor participant herein, or our heirs, successors, and assigns, to hold harmless and defend Immaculate Heart of Mary/Pope John Paul II Catholic Church and Missions, its officers, directors, employees and agents, and the Diocese of Pueblo, its employees and agents, chaperones, or representatives associated with the activities, from any claim arising from or in connection with my child participating in the activities, or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate Immaculate Heart of Mary/Pope John Paul II Catholic Church and Missions, its officers, directors and agents, and the Diocese of Pueblo, its employees and agents and chaperones, or representative associated with the activities for reasonable attorney’s fees and expenses which they may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of Immaculate Heart of Mary/Pope John Paul II Catholic Church and Missions or the Diocese of Pueblo.
  
  Offsite Activity Consent REQUIRED I Agree and Consent Please fill out this field.
  
  Photo Consent
  
  I/We consent to the Diocese of Pueblo to take, use, disclose, post or publish photographs, slides, and video/audio recordings of my child for official parish or diocesan communication purposes via print or internet-based media, including, but not limited to, parish/diocesan publications and parish/diocesan-sponsored websites, including parish/diocesan social networking websites. I/We understand that by giving such consent, a photograph or video/audio recording of my child may be disseminated or disclosed to the general public. If photo consent is given, I understand that my teen's name will NOT be used.
  
  Photo consent I Agree and Consent
  
  Youth Code of Conduct
  
  Youth participants will: • Project an image of Christian consideration, sensitivity, and respect to everyone and to the property around them through language, dress, and behavior. (Note: Prohibited attire includes short shorts, tank tops, any clothing with inappropriate writing/images, exposure of mid-drift or undergarments, or any reference to profanity, tobacco or alcohol products including insignias or advertisements.) • Refrain from inappropriate touching and verbal harassment. • Respect the property of others (public, private, personal). • Refrain from actions that could result in injury and/or damage to property. • Adhere to stated curfew, remain as a group and refrain from being a click among selected peers. • Attend all scheduled activities, arriving promptly, and staying for the entire event. • Act as a lady or gentleman and refrain from any sexual misconduct. • Behave in a manner consistent with the spirit of the event or activity. • Report problems of any kind to a trusted adult chaperone. • Adhere to rules related to cell phone/electronics usage, as set by the trip leaders/adult chaperones. • Follow all rules set by the trip leaders/adult chaperones. Youth participants will not: • Possess weapons of any kind. • Purchase, possess, consume, or distribute alcohol. • Purchase, possess, consume, or distribute illegal drugs. • Purchase, possess, distribute, or use nicotine or marijuana of any kind, including vaping/ecigarette products. • Enter an area/room that is designated for the opposite gender (ie, girls cannot enter a boy’s sleeping area or vice versa). • Engage in any form of sexual activity or peer sexual harassment. • Purchase, download, possess, view, or distribute pornography.
  
  To be acknowledged by Youth Participant
  
  By signing this, I agree to abide by the Youth Code of Conduct. I realize and agree, that if I do not abide by these rules, I will lose the privilege of attending a scheduled activity and could be sent home at the discretion of the adult leaders at my parent’s or guardian’s expense. I understand that my personal belongings are subject to random checks by adult chaperones and I will be responsible for all consequences of my behavior.
  
  Youth Minor Consent REQUIRED I Agree and Consent (Youth Minor) Please fill out this field.
  
  Parent REQUIRED I have gone over the Youth Code of Conduct with my teen and acknowledge if the teen breaks the code of conduct they may be sent home at my expense. Please fill out this field.
  
  General Parent Consent
  
  I, the above named Parent/Guardian, Agree and Consent for my minor child named above to attend BCYC in Atchinson, KS from June 19-23, 2025. REQUIRED I Agree and Consent Please fill out this field.
  
  IMPORTANT! Your teen's BCYC application will NOT be considered complete until the online registration is submitted AND the $100 registration fee is received in full. A credit card or ACH payment may be made by clicking the "Pay Now" button below. If you prefer to pay with cash or check, click the "Pay Later" button below and deliver payment to the Parish Office during business hours. Online registration and payment must be received by March 10, 2024.
  
  Steubenville Registration100.0
  
  Total:
  
  Submit
  
  Pay Now
  
  Pay Later
  
  This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.